The art &amp; science of prescribing

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Applied Evidence

The art & science of prescribing

J Fam Pract. 2015 July;64(7):400-406A

Swati Shivale, MBBS

Mantosh Dewan, MD

When medical interventions fail, it’s often because there is no mutually agreed-upon regimen for the patient to follow. The authors provide evidence-based strategies to improve adherence, plus an easy-to-use prescribing checklist.

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References

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PRACTICE RECOMMENDATIONS

› To increase adherence, give patients treatment options, ensure that they participate in discussions of treatment, and empower them to reach "informed collaboration" as opposed to informed consent. A
› Ask patients to tell you in their own words what they understand about the treatment they have chosen. A
› At each follow-up visit, anticipate nonadherence, ask nonjudgmental questions about missed medication doses and sexual adverse effects, and offer simple solutions. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Medication nonadherence is a major—and remediable—contributor to poor outcomes, leading to approximately 125,000 preventable deaths,¹ worsening of acute and chronic conditions, and billions of dollars in avoidable costs related to increased hospitalizations and emergency visits each year.^2,3 Nonadherence rates are 20% to 30% among patients being treated for cancer and acute illness³ and 50% to 60% for chronic conditions, with an average of 50% of all patients taking their medication incorrectly—or not at all.^2,4,5

What’s more, nonadherence disrupts the physician-patient relationship⁶—a serious problem, given that feeling understood is often the most critical component of recovery.^7-9

With that in mind, the words used to describe the problem have changed. Compliance and noncompliance, the older labels, were based on the assumptions that patients are passive recipients of medical advice that they should follow without question and that they are to blame for not doing so. Adherence and nonadherence, on the other hand, emphasize mutual agreement and the patient’s freedom to follow the doctor’s recommendations or not, without blame if he or she decides not to do so.¹⁰

Many systemic approaches have been tried to maximize adherence, including disease management (eg, Web-based assessment tools, clinical guidelines, and call center-based triage), smart phone apps¹¹ (for reminders and monitoring), and paying for or subsidizing the cost of drugs for those who can’t afford them. All have met with limited success.¹² Based on a thorough review of the literature, we suggest a different approach.

Evidence-based efforts by clinicians are the key to effective prescribing and maximal adherence. In the text and table that follow, we summarize physician and patient factors that influence adherence and present optimal prescribing guidelines.

Listen carefully, then respond

Whether patients are seeing a primary care physician or a specialist, they want their doctors to spend more time with them and to give them more comprehensive information about their condition.^13-15 The interaction should begin with the physician listening carefully to the patient before responding, but all too often this is not the case.

Family physicians have been found to interrupt patients 23 seconds after asking a question.¹⁶ To improve communication, listen quietly until the patient finishes presenting his or her complaints and agenda for the visit. Then ask, “Is there anything else that’s important for me to know?”¹⁷

Be more forthcoming

It is equally important for physicians to respond fully, but this is often not the case. A study involving internists found that in patient encounters lasting 20 minutes, physicians devoted little more than one minute, on average, to explaining the patient’s medical condition. The research showed that many physicians greatly overestimated the time they spent doing so.¹³

Studies have also shown that clinicians tell patients the name of the drug they’re prescribing 74% of the time and state its purpose 87% of the time, but discuss potential adverse effects and duration of treatment a mere 34% of the time. More than 4 in 10 patients are not told the frequency or timing of doses or the number of tablets to take.¹⁸

To improve communication, take the following steps when it’s your turn to talk:

Avoid medical jargon. Technical language (eg, edema) and medical shorthand (eg, history) is a significant barrier to patient understanding. In one study of more than 800 pediatrician visits, such speech was found to be detrimental more than half of the time. Although many mothers were confused by the terms, they rarely asked for clarification.¹⁹

Listen quietly until patients finish presenting their complaints and reason for the visit, then ask whether there is anything else that's important for you to know.

It has been suggested that doctors and patients have engaged in a “communication conspiracy.”²⁰ In one study, even after obstetricians and gynecologists had identified terms that they knew their patients did not understand, they continued to use them, and in only 15% of visits where unfamiliar terms were used did the patients admit that they did not understand them.²¹ Part of the problem may be that patients believe they must be seen as undemanding and compliant if they are to receive optimal attention from their physicians.²²