There can be a big difference between a patient's commitment to the plan while still in the Doctor's office, their immediate decisions on leaving about adherence and the full follow through to complete the course over days, weeks, or months. We can opt out at any of these stages. The poor uptake of medical advice remains a major challenge to the medical profession, but it could be argued that within many patient's health understanding there lurks a healthy scepticism related to medical advice, and that if doctors really do wish to influence their patients to do what they think is good for them, they had better be jolly certain that they are right.
We are more likely to adhere to treatment if we understand and believe the explanation. Some of us will adhere because it is a doctor who has told us to; most of us will adhere if our own understanding seems to match that of the doctor and our agenda is shared, this is what is meant by concordance. A shared understanding between patient and doctor should be the gold standard of all patient doctor encounters.
PRESSURE SORES STAGES
A whole issue of the British Medical Journal was devoted to this topic, entitled from compliance to concordance, 1.10.2003.
There is a fascinating area that doctors know very little about -what lessons do we patients learn from whether we follow our advice or not?
99% of us act rationally in terms of our own health beliefs which sadly may not themselves be rational.
For example, Patient A goes to the doctor wanting penicillin for her sore throat. She gets it, gets better and has her health belief confirmed- that penicillin cures sore throats.
Patient B, does exactly the same but does not get better- what lessons has he learned? That penicillin does not cure sore throats? That it was not a 'strong' enough antibiotic and that the doctor was ineffective in choosing the right one? e.g. 'I've always had the green ones before, these red ones are useless.'
That the doctor was right all the time and it was a virus that did not respond to penicillin or that there may be something very serious that the doctor missed? That this doctor is no good and that he will try another one next time? Etc. There is another possibility with patient B -that of partial compliance. He might be one of the 1/3rd that takes a few pills here and there but not enough to get adequate blood levels (but he may still think he has followed instructions).
What about patient C? He only came for a sick note but was given tablets he did not want and did not take and he still got better.
'I don't know what they teach doctors at medical school, always giving pills for no good reason.'
Or patient D, she was given penicillin but did not take it because it had given her thrush last time, but now she feels both unwell and guilty. If she goes back to the doctor she might well lie about taking the tablets. These are just some examples of the sort of messages that we patients learn from whether we do or do not take medical advice. How many of these sorts of messages are doctors aware of? Precious few I fear.
A major problem with communication between doctor and patient are the different frames of reference. Doctors are taught scientifically; they learn thousands of new words and have models of disease imprinted in their brains. We patients are not like this. Both doctors and patients have reasons for believing and doing what they do, the trouble is these reasons are different.
Take hypertension, a doctor's disease if ever there was one: until the advent of cheap electronic machines only professionals could diagnose this condition. Doctors insist to their patients that high blood pressure produces no symptoms and can only be effectively treated by regular medication and frequent monitoring. This is the concept of the asymptomatic risk factor. Most of us can not understand this and use more obvious folk explanations to help us cope with what we perceive as an illness. The result is the adherence nightmare already alluded to.
Most of us think hyper-tension is a description, and take our medication depending on how we feel. If we are feeling headachy, a bit tense and edgy then to us it is obvious that we are hyper--tensive and need to take our tablets, but on those days we are feeling serene and relaxed then it is obviously not necessary to take the tablets. All quite logical but using a non medical frame of reference.
Whether or not we adhere to the treatment leads to the final outcome in our learning circle. As Stimpson and Webb (1975) pointed out:
"The crucial paradox ...is that in the consultation the doctor makes the treatment decisions; after the consultation, decision making lies with the patient".
