Map of life expectancy at birth from Global Education Project.

Wednesday, March 21, 2007

Doctor's Orders

I would venture to say that the single most widely studied issue in the sociology of medicine is what we used to call compliance, but which it is now politically correct to call adherence. That means, why do people do what the doctor tells them to do, or not do it, and how can we get them to do it more consistently? There is usually an unspoken assumption that they ought to do what the doctor wants. The shift from "compliance" to "adherence" was intended to acknowledge that the assumption might be incorrect, but it didn't really have any effect on people's thinking about this.

For all the overhyped and overprescribed pills out there, including ones that shouldn't be on the market at all, I will most definitely affirm that there are pills that you would probably want to take under the right circumstances. There is also plenty of standard medical advice that none of my readers will argue with, such as not smoking, drinking less than a fifth of Old Grandad a day, being physically active, etc., and that there is dietary advice which is very important for some people, such as people with diabetes.

Of course, given the inherent biases in funding and in the culture, most of the attention goes to pill popping. It turns out that in the case of long-term medication "regimens,"* as we call them, such as medication for blood pressure control, only about half of the people continue to take the pills consistently as prescribed. In the case of antiretroviral medications for HIV, doctors are obssessed with the problem, because the regimens can be relatively difficult to follow, people with HIV often have particular reasons why it's hard for them to follow a complicated drug regimen, and the standard of adherence doctors believe is necessary is very high (taking 90% or more of recommended doses). Even short courses of medication, particularly antibiotics, are problematic. Many people stop taking antibiotics as soon as they feel better, but doctors believe this increases the risk of letting drug resistant strains of bacteria loose in the world.

I have been studying this problem for a long time, and like my colleagues, I'm sorry to have to say that I still don't know a whole lot about it. Certainly people need to be given the minimum necessary conditions for adherence, which are:

  1. They have to understand clearly what they are supposed to do (and in the case of most people, probably have some idea of why they are supposed to do it, although there are some who don't really care about that); and

  2. They have to be able to afford to buy the pills and obtain them with reasonable convenience.

Once we've provided those conditions -- which we very often do not -- it's far from clear why Fred takes the pills and Alice doesn't. Researchers have looked into all sorts of basic facts about people -- gender, age, race and ethnicity, level of formal education, etc. etc. -- and it doesn't show a whole lot. Even if it did, that wouldn't tell us what to do about it. Of course, people are less likely to be adherent when the pills have unpleasant side effects, but see previous sentence. Active drug addicts and alcoholics have trouble taking their pills, but that's a special case.

They've tried all sorts of interventions -- patient education, physician communication strategies, etc. -- but only the most intensive, expensive, and probably unrealistic ones, not far short of having a nurse move in with you, really seem to work.

People just do what works for them, basically. They take the doctor's opinion into account, but if it gets to be too much of a pain in the gazongas, if it reminds them all the time that there is somehow supposedly something wrong with them, if it's costing $15 a month they'd rather spend on lottery tickets, or if they just have a vague idea that it's better not to be taking a lot of pills all the time, they'll take the pills when they feel like it, or not at all. And so far, that's still the bottom line.

How about you? Are you supposed to be taking pills? Are you doing it? Why or why not?

* "Regimen" sounds military to most people, but etymologically it's really derived from "regime," meaning government, and refers to rules or good order. However, the set of available drugs to treat a condition is called the physician's "armamentarium," indeed one of those classic military metaphors in medicine.

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