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Why good communication between doctor and patient may be bad for patient ‘compliance’

Posted Jan 18 2013 10:10am

Good communication is, I think, the bedrock of a good relationship between a doctor and a patient. One thing that frustrates some doctors is when their patients do not take their advice. A major gripe can be the failure to take medications as prescribed. In a recent study published in the journal JAMA Internal Medicine, about a third of a sample of patients were found to not be taking their medication as prescribed by their doctor.

The researchers involved in this study were most interested in what aspect of the doctor-patient relationship might influence patient ‘adherence’, and in particular whether the quality of communication in the relationship influenced this [1]. It turns out that patients were more likely to act on their doctor’s advice if they felt their doctor listened more to them and involved them more in the decision-making process. No major surprises here, I think.

I’m all for good communication between doctors and patients, as I alluded to above. I’m also a big believer in we doctors being honest and transparent regarding the likely benefits of any treatment we advise, where this is known. This study actually focused on individuals who were taking at least one medication for diabetes, high blood pressure or ‘raised’ cholesterol.

In the case of cholesterol-reducing medication, we know much about the likely benefits and risks. For example, we know that in individuals with no history of previous heart attack or stroke (as is most likely to be the case), then statins do not reduce the risk of death. We also know that the individual is very unlikely to see benefits in terms of protection from heart attack (studies show that about 1-2 people per 100 benefits here over some years). However, there’s actually quite a good chance (about 20 per cent) that the person will experience one or more adverse effect from the statin including fatigue, muscle pain, liver damage, kidney damage and diabetes. In summary, the reality is the benefits of statins are likely to be outweighed by their risks.

Just imagine, for a moment, what might happen if doctors were to communicate these facts to their patients? I’ve actually had these communications many, many times with people and I can’t recall a single time when someone has still expressed a strong desire to take statins.

I agree that good communication is likely to improve ‘compliance’. However, in the case of statins, I reckon good communication based on the facts would cause adherence to drop like a lead balloon.

The case with statins is not isolated: there’s lots of things that we do and promote in medicine that are not particularly effective, and it’s good to see growing recognition of this. It’s through this sort of debate that we’ll finally see people being able to make truly informed decision about things like prostate and breast cancer screening and whether to take antibiotics for their sore throat. As the information gets out, individuals are becoming increasingly savvy. And the result is people are becoming increasingly less inclined to take their recommendations at face value. Trust me, when people fail to do what their doctor advises, it’s not always a bad thing at all.

1. Ratanawongsa N, et al. Communication and Medication Refill Adherence – The Diabetes Study of Northern California. JAMA Internal Medicine ONLINE FIRST 31 December 2012

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