It’s funny how a document or an idea can float around for many years then re-emerge with new relevance much later. In reading about “Health 2.0” in the BMJ recently I followed the links to the Demos organisation and downloaded their excellent document “The Talking Cure“. One of the references listed in that document was a publication by the Royal Pharmaceutical Society of Great Britain, published back in 1997, tackling the issue of “non-compliance” – where patients don’t actually take their medicines as they’ve been prescribed. This is a fascinating document. The conclusion it reaches is that it’s time to stop thinking about “compliance” and start thinking about “concordance”.
Here’s their definition of “compliance” –
The patient presents with a significant medical problem for which there is a potentially helpful treatment. What the doctor or other health care professional brings to the situation – scientific evidence and technical expertise – is classed as the solution. What the patient brings – ‘health beliefs’ based on such qualities as culture, personality, family tradition and experience – is classed by clinicians as the impediment to the solution. The only sensible way out of this difficulty would appear to be to bring the patient’s response to the doctor’s diagnosis and proposed treatment, as far as possible into line with what medical science suggests.
and, here’s their definition of “concordance”
The clinical encounter is concerned with two sets of contrasted but equally cogent health beliefs – that of the patient and that of the doctor. The task of the patient is to convey her or his health beliefs to the doctor; and of the doctor, to enable this to happen. The task of the doctor or other prescriber is to convey his or her (professionally informed) health beliefs to the patient; and of the patient, to entertain these. The intention is to assist the patient to make as informed a choice as possible about the diagnosis and treatment, about benefit and risk and to take full part in a therapeutic alliance. Although reciprocal, this is an alliance in which the most important determinations are agreed to be those that are made by the patient.
This is such an important shift in thinking.
The full report considers what this means for “Evidence Based Medicine” (EBM). It does represent a challenge but it doesn’t undermine EBM principles. EBM is basically clinical epidemiology. It’s a statistical technique which focuses on the results of experiments conducted on groups of volunteers. It helps us to understand the potential of an intervention. However, the reality of an intervention has to be patient based. A painkiller might be “proven” in EBM terms, but might totally fail to relieve a particular patient’s pain. In fact, that’s partly the reason there are so many “proven” drugs which claim to do the same thing – they might have demonstrated their potential to something but only the patient can decide whether or not they “work” for them.
This is encouraging. For too long patients’ experiences have been dismissed as “anecdotal” and, frankly, irrelevant. That thinking has to change.
Heroes Not Zombies 
I am always amazed when the “experts” pronouce something to be a “new” thing when it has been recognized for years by doctors and patients. (And even more so when it was written off a decade earlier.)
A good example is Aldactone. Like neck-tie fashion that goes from wide to narrow, I’ve seen the drug go through three cycles. At the moment it is hip in the U.S. and all the “good” doctors use it, but that could change next week with a new “discovery.”
Dr. B
I guess when you’ve been doctoring for as many years as you or me, Dr B, you’ve seen many of these neck-tie drug fashions! Well said, as ever.
What always amazes me is how “experts” manage to be so doubt-free! They always KNOW, absolutely, completely, better than anyone else (well better than YOU anyway if you happen to disagree with them!)
You know it’s been taught for quite some time that good GPs (“general practitioners” – our UK version of what you call “Primary Care Physicians”) have the “ability to handle uncertainty” as a key skill but some “experts” handle uncertainty by not having any. That never strikes me as clever.