Reviewing medical evidence has become such a habit that sometimes it feels almost impossible to think independently. I’ve always been a top-down thinker; I go with my gut instinct, and then look for the evidence to support my assessment.
The problem is that very often it feels like what patients need most is not the precision of a particular etiology or the selection of a medication that is perfectly and precisely tailored to their condition and comorbidities; what they need is education about what it means to maintain their health, and practical strategies for how to do so. And my long hours delving into the literature for evidence on how best to do that have been less helpful than I’d hoped.
Says the patient, “I take my medications every day.” Literature on this subject is, in fact, adequately robust for me to mistrust those words when uttered by the majority of patients. For example, toxicological monitoring (which is pretty sensitive, if not practical in the day-to-day clinic setting) reveals that a whopping 50-60% of patients with resistant hypertension are non-adherent with their medications . A cohort study done in Quebec and published in 2014 found that 31.3% of 37,506 first-time prescriptions were not even filled, much less taken .
I blame myself for the patient’s fib. If my patients feel that they cannot be honest with me about missed doses, that’s a reflection of my own failing to develop rapport. One of the best pieces of advice I have received in medical school is to start with, “I know that when I need to take medications it’s very hard for me to remember every dose. How many pills do you think you’ve missed this week?” I’ve put it to good use, but where is the literature on how to ask questions that will yield honest answers? It may be there, but I’ve yet to find it, outside of maybe the most psychodynamically-oriented mental health journals.
There is, however, a growing body of research into validated tools to assist in screening for medication adherence. My personal favorite is the brand-spanking-new Measure of Drug Self-Management, abbreviated as MeDS—cute, right ? But it’s not the catchy name that draws me to this newly-developed and validated 12-item questionnaire; rather, it’s that the authors specifically sought to develop an inexpensive tool that is considerate of the wide range of patient behaviors (and barriers) and that applies to a diverse range of patients with variable literacy levels :
- Did you forget to take your (insert drug name) at any time last week?
- In the past month have you stopped taking (insert drug name) for any reason without telling your doctor?
- I often forget to take my medicine.
- I am organized about when and how I take my medicines.
- I have a hard time paying for my medicines.
- The print instructions of my prescription bottles are confusing.
- Having to take medicines worries me.
- I often have a hard time remembering if I have already taken my medicine.
- I do not take my medicines when I am feeling sad or upset.
- My medicines disrupt my life.
- When my medicine causes minor side effects, I stop taking it.
- The idea of taking medications for the rest of my life makes me very uncomfortable.
The tool is practical, efficient, and patient-centered–all of the things I strive to be. However, as it has only been publicized within the past month, I’d like to see some more validity testing before investing in the MeDS scale myself. Part of the reason for my skepticism is a lack of evidence-based interventions that physicians can recommend to help patients improve their medication adherence. A Cochrane review published in 2014 analyzed a total of 182 randomized controlled trials aimed at enhancing medication adherence for a wide range of patient populations and medical conditions, and concluded that the methods used for researching such interventions were insufficiently advanced . In essence, no conclusions can be drawn on the basis of existing research because we are not sufficiently adept at performing this research in the first place.At what point, then, do I give up on finding the evidence to back up my instincts? Do I withhold my suggestions from patients until I know that we’re on the right track? Do I start doing the research myself? How could my methods possibly be more advanced than those of the Cochrane review? It brings me back to how I framed the issue for a patient who was frequently skipping breakfast: “You should try to get more of your calories in earlier in the day. There’s research to support that. I’ve heard the explanation that when you eat in the morning, that’s fuel for your body and you burn those calories during your daily activities. But the calories that you eat before bed go right into storage, because you’re just going to bed and not doing anything active. That’s just anecdotal, though—I’m not sure what science says about that. It kind of makes sense though, right? I’m just throwing it out there to help you feel motivated and empowered to change the way you eat, so that you don’t follow in your dad’s footsteps of having a heart attack at age 50.” So I printed out the Mayo Clinic page on Mediterranean diet and sent the patient home to do some reading about plant-based diets. I’m still, however, flooded with a sense of inadequacy and powerlessness when it comes to educating myself on how to foster the trust of my patients and educate them appropriately.
Rebecca Sussman is a 3rd year medical student at NYU School of Medicine
Peer reviewed by Michael Tanner, Associate Professor of Medicine, Executive Editor, Clinical Correlations
Image courtesy of Wikimedia Commons
- Pandey A, Raza F, Velasco A, et al. Comparison of Morisky Medication Adherence Scale with therapeutic drug monitoring in apparent treatment-resistant hypertension. J Am Soc Hypertension. 2015;9(6):420-426. http://www.ncbi.nlm.nih.gov/pubmed/26051923
- Tamblyn R, Eguale T, Huang A, Winslade N, Doran P. The incidence and determinants of primary nonadherence with prescribed medication in primary care. Ann Intern Med. 2014;160(7):441-450. http://annals.org/article.aspx?articleID=1852865
- Bailey SC, Annis IA, Rueland DS, Locklear AD, Sleath BL, Wolf MS. Development and evaluation of the Measure of Drugs Self-Management. Patient Preference and Adherence. 2015;9:1101-1108. https://www.dovepress.com/development-and-evaluation-of-the-measure-of-drug-self-management-peer-reviewed-article-PPA
- Nieuwlaat R, Wilczynski N, Navarro T, et al. Interventions for enhancing medication adherence. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD000011. DOI: 10.1002/14651858.CD000011.pub4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000011.pub4/full