and the flip side of that is . . .

So yes, physicians would like for their patients with HIV to come as close as possible to taking their pills on time, every time. But in reality, there is a bit of wiggle room -- the probability of viral drug resistance developing because of a single missed dose, or a whole day, here and there, is quite low. And the situation is generally similar in other chronic diseases. Recent studies have found that when people with diabetes knock themselves out to achieve even stricter than standard glycemic control, there really isn't any benefit. If you miss your blood pressure meds one day you really aren't going to drop dead. You should just take them the next day and move on.

So what do you tell somebody who's doing the best they can and managing to take, say, 80% of their doses? Well, one thing you don't tell them is that they're failng, it just isn't good enough, they have to do better or the guy in the black cloak wit the big sickle is gonna come calling. It's human nature. If I'm trying, but all the feedback I get is that I'm not cutting the mustard, what am I going to do? Give up, most likely. That's why people drop out of school. Quite often, that's why they become drug addicts in the first place: because they are repeatedly told that they're failures, they just aren't good enough, YOU SUCK.

Unfortunately, I'm hear to tell you that when it comes to adherence to medical advice, quite a few doctors haven't gotten that memo. So here's my theory: if somebody is managing to take 80% of their meds, or if they have ever managed to stick with the program for even one week, or if they even say they want to make it happen, that's what you work with. Go with the positive. Go with the affirmation.

"That's great that you're taking the meds, and you're taking 80% of them on time, it's a major commitment and you're hanging in there. So let's make a plan so that you can keep doing it, and get even better. Let's have you think about the times when you miss, or you're late, and figure out why that happens, and see if we can't fix the problems, one at a time. It doesn't have to be more than you can do, let's just make it easy and keep building on success."

So you don't tell the person what to do, you don't scold, you don't lecture, you don't threaten. That's exactly what doesn't work. You encourage, you support, you affirm, you facilitate. That's what does work.

We make aspiring doctors spend 7 years (or more) of sleepless nights getting all the knowledge of the Library of Congress stuffed into their heads (most of which they soon forget), but we don't teach them that. Go figure.