Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, January 21, 2007

Marble Dinosaur Egg*: Assessing Medication Adherence

*My version of a "clinical pearl."

FIRST IN AN OCCASIONAL SERIES

"Clinical Pearl" is the name given to those little hints that may not be taught in medical school or postgraduate training, but have been discovered or devised over the years by us old coots who may still know a thing or two.

Via KevinMD comes this article about patients who lie, both about their medications and other things, occasionally to their severe detriment. Not knowing exactly what meds (and how much) a patient is actually taking can lead to fatal outcomes of prescription interactions.

Various ways of assessing medication adherence (a work I prefer to compliance, which sounds to me like bending patients) have been suggested, including specifically worded questions like, "“A number of my patients don’t take their medication as prescribed and they do it for a variety of reasons. What do you think might be going on with you?” Personally, I find that awkward and stilted; so here is what I have come up with.

First I ascertain medication name, dosages and frequencies. For folks who answer, "Whatever you've got down there, Doc" I smile and say, "This is sort of a quiz to make sure you know what you're taking." Most people are fine with that. Many have taken to carrying a small card or slip of paper with their meds, which I use to review and double-check with my chart. Once a year or so I'll ask them to bring in all their med bottles, and we'll go through them together. (The old "brown bag" review. One time I had fun teasing a long-time patient about her inability to follow directions; how could we do a "brown bag" review of her meds if she brought them in a plastic grocery bag?)

Finally, my magic "adherence" question:
(in a conspiratorial tone, face scrunched a little, with a tiny nod) How often do you forget to take them?
The implication is that everyone forgets now and then, I'm not going to be angry, and I really need to know. It works like a charm:
  • "Sometimes on the weekends, but I'm usually pretty good."
  • "Honestly, I only get that second dose in once a week or so."
  • "I'll be honest with you, Doc; maybe 3 or 4 times a week."
  • "Never! I take them every morning right after I brush my teeth."
and stuff like that.

Remember: the secret to getting patients to tell you the truth about meds -- or anything else, for that matter -- is to make sure they don't feel judged. And the only way to accomplish that is to refrain from being judgemental. (Although once more, the Tenth Law of the Dinosaur rears its impressive head: "Simple" and "Easy" are not necessarily the same.)

13 Comments:

At Sun Jan 21, 05:04:00 PM, Blogger emmy said...

So, if I was in your office and I told you that occasionally on Saturdays because that day tends to be a slack day for me, I'll forget my morning meds, but I take them in the evenings and only miss a dose about once a month or so...you'd think that three times a month or so I'm not taking one dose? What would you do, slap me on the hand? I know that I should be able to get my act together on Saturdays, but I don't want too. Sometimes I just want to sit on my bed wrapped in a quilt and read and once a month on Saturdays is about all that I can manage for now. But if I told my primary care doc that, she'd go into a discussion on depression. If that's depression, leave me alone. I'm enjoying it.

 
At Sun Jan 21, 07:21:00 PM, Blogger #1 Dinosaur said...

I didn't say anything about what I do with the information; only how I go about obtaining it accurately.

I never get angry or upset at patients for anything med-related. As I point out to them, it's their health, not mine. I also can't do anything about what's happened in the past. All I can do is figure out a way to help the patient do the best they can going forward.

In the case you describe, a lot would depend on the medication. If it were a statin, I wouldn't care. If it were an antidepressant, I'd ask if you're having missed-dose-related side effects and point out how they could be alleviated by taking it. If it were Synthroid, I'd ask that however often you skip it to do so consistently. (Same goes for statins, actually.) If it were a BP med, I'd point out how I'd hate to have your weekend ruined by a stroke (if it were a high dose of an immediate-acting type med like a beta blocker.) And so on...

I won't judge you if you won't make assumptions about what I'm going to do when you come clean about suboptimal adherence. (Actually, I won't judge you even if you do.)

 
At Sun Jan 21, 08:36:00 PM, Blogger Bohemian Road Nurse... said...

Aah, this is a subject dear to my heart--patient compliance. I like to boast that I can "spot a lyin' patient at 25 yards in the dark". But seriously, the good thing about road nursing is that eventually I'll gain the patient's trust and wring the truth out of them. (Then I can resort to my favorite threats: "Okay, 'fess up sweetheart or I'm gonna tell the doctor on you...") For notifying the doctors about problems like elevated BP's or blood sugars, I instruct our nurses to always help the doctor out by including a note about the level of med & diet compliance.

 
At Sun Jan 21, 09:06:00 PM, Anonymous Anonymous said...

I can't imagine not taking meds as prescribed, or if I think I shouldn't be taking a med I'll call the doc about my concerns. Of course it's been many years since I got a prescription for anything, except pain meds when I broke my hip, but I certainly didn't take those as prescribed for very long because I didn't need to. And I let the surgeon's office know what I was doing, though it felt silly to do so, since obviously pain meds are for when you have unbearable PAIN. Right?

What I have learned by reading medblogs is to let a doctor know what vitamins and supplements I take. Hadn't thought of that before.

Thank you for using the word "adherence" instead of "compliance"...the latter carries a load of implication of subservience, which is insulting, actually.

 
At Sun Jan 21, 09:33:00 PM, Blogger Bohemian Road Nurse... said...

I don't use the word "compliance" to be "insulting" or to imply that a patient must be "subserviant". I use the dang word because that is the term that I was taught to use in every single nursing course I ever attended---and also because that is the word that I am required to use in my documentation per Medicare/Medicaid guidelines. (And I am quite non-compliant about a few things myself, heh!)

 
At Mon Jan 22, 06:16:00 AM, Blogger #1 Dinosaur said...

BRN: "Adherence" is rapidly gaining acceptance as a synonym for "Compliance." It may be no more than PC-ness creeping into the field, but what the hell.

 
At Mon Jan 22, 08:44:00 AM, Blogger Bohemian Road Nurse... said...

Thanks, Doc!

 
At Mon Jan 22, 08:03:00 PM, Anonymous Anonymous said...

Bohemian Nurse, I'm aware that 'compliance' is a word without subservient implications for most doctors (and nurses, of course). But for me personally it does have that implication and so I bristle at it. My feelings about the word used does not in the least affect my feelings toward the medical person using it since I do understand his/her concerns.

BTW, I recently found your blog and check daily for new posts (and have treated myself to reading the archives)....really, you are fantastic!

 
At Tue Jan 23, 01:04:00 AM, Blogger Dreaming again said...

I don't forget my meds. But then, my meds have become so dadgum routine ...and ...when you take one medication every 3 hours it makes it easier to not forget those once or twice (even 3 times) a day medications. Mestinon for Myasthenia Gravis, is not likely to be forgotten or overlooked.

I guess that would be a positive thing about Mestinon huh? *rolling eyes*

 
At Mon Apr 23, 12:12:00 AM, Anonymous RJS said...

An old post, but why not?

I'm a young guy. I carry a cell phone. When I need short-term abx (which I use PRN for 10-day intervals), I set alarms on my cell phone.

9am, 2pm, 9pm

I never forget that way.

Might suggest it if you've got patients who really shouldn't miss a dose of anything, or if they're on meds that need to taken at a very specific time.

 
At Mon Apr 23, 06:27:00 AM, Blogger #1 Dinosaur said...

rjs: This post is about ASSESSING medication adherence. ENHANCING it is a matter for another post (or thousand.)

 
At Mon Apr 07, 04:16:00 PM, Blogger Lily said...

Why would someone not take the medications his doctor has prescribed? Because he can’t afford them! I found a prescription discount card that helps lower the cost of prescription medications for people who don’t have health insurance. It’s at www.rxdrugcard.com. The membership fee is only $4.50 a month. Drug prices are shown on that website to check before you enroll. You can save up to 80%. Generics and brand-name drugs are both covered.

 
At Thu Dec 25, 12:57:00 PM, Anonymous DrLucyVanPelt said...

As a pharmacist, I have actually had a patient YELL at me NOT to call the PCP for a refill because she was a afraid that I would "rat her out" for not taking her thyroid meds as prescribed. Still shaking my head over that one...

 

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