The gift of grace

Diane Kelsall

Maybe not today. Maybe not tomorrow, but soon and for the rest of your life.

Humphrey Bogart (as Rick)

Casablanca,1942

When I was first in practice I had a patient, a university student, who developed strep throat. Because he was allergic to penicillin, I prescribed him a course of erythromycin. He came back to see me after he had completed the antibiotics. I was shocked by his appearance. He was pale, had dark circles under his eyes, and had lost a substantial amount of weight. He looked far worse than when he had first presented with pharyngitis. Upon questioning, I discovered that he had been vomiting for the entire week and had been unable to keep any solids down. I explained that he had experienced an adverse effect of the erythromycin, but wondered why he hadn’t come in earlier to let me know. He told me that I had instructed him to take the antibiotic and to return when it was finished. That he had done. Exactly as I had instructed.

It was later in my practice that I realized that many of my patients were much less faithful to my directions. Some didn’t fill their prescriptions, while others seemed to take their medications in a manner that could only be described as random. When a patient wasn’t improving, I learned to specifically ask about the medication or other therapy I had prescribed before adjusting the dose or switching modalities. Was the patient actually taking the medication or therapy as prescribed?

I also learned that I needed to involve the patient in decision making about the proposed medication or therapy. At the beginning. Before I wrote the prescription. Sometimes a therapy that I thought was fairly trivial had huge implications for the patient. For example, starting a patient on hydrochlorothiazide for hypertension might have multiple meanings for him:

He now has hypertension just like his father who died of a myocardial infarction at 58 years of age.
He has to take a pill every day for the rest of his life.
He is no longer well, but sick.
This prescription is not for the latest medication that his friend is on. Perhaps the doctor doesn’t keep up with the latest literature.
He doesn’t have any symptoms. Maybe the doctor made a mistake.
An herbal medication is probably just as good.
What if the drug causes impotence, just like his friend’s blood pressure medication did?
Maybe the doctor is in cahoots with the pharmaceutical company.
He doesn’t have a drug plan and will have to pay for the medication.
How on earth is he going to remember to take a pill every day?

No wonder some patients struggle with the decision to fill their prescriptions or take the medications once they have picked them up at the pharmacy. In this issue, several research papers look at factors affecting patient adherence to prescribed therapies. Lau et al (page 394) explore patient perceptions about strategies to improve adherence to osteoporosis therapies. Dolovich et al (page 384) look at the influence of patient expectations on medication use.

While many factors come into play in adherence to therapies, the research shows that the relationship between the patient and the physician is key. A good patient-physician relationship is an important indicator of whether patients will discuss their information needs or adverse effects with their physicians. Patients who trust their physicians and respect their judgment will be more likely to accept their physicians’ advice.

In a related paper, Sinclair et al (page 404) found that patients who had good relationships with their physicians were more likely to report receiving advice on lifestyle interventions (diet and exercise) from their physicians than those who had poor relationships and poor communication.

So, the patient-physician relationship appears to work both ways regarding adherence to therapies. If we have a good working relationship with our patients, we are more likely to engage with them about therapeutic choices—and our patients are more likely to be receptive to our recommendations. Makes sense, doesn’t it?

We need, however, to be truly open to discussion. To allow our patients time to explore their options. To address the fears or beliefs that might seem unrealistic to us. To offer our patients understanding, courtesy—and, yes, grace when they choose to reject our well-intentioned advice. Because tomorrow is another day.