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Adherence to medical advice and communication with the patient

15 January 2023

It has probably happened to everyone that we have discontinued medication prescribed by the doctor or taken it differently from what the doctor ordered. We have not followed our diet, not fully undergone the recommended rehabilitation or not sought the advice of a specialist recommended by the attending physician. And we act in spite of the fact that we all realise that the extent to which we implement the doctor's recommendations may determine the success of our treatment, and whether our contact with the doctor will be a rewarding or a disappointing experience.

Few patients fully adhere to medical recommendations, and the statistics are very worrying. Patient non-adherence to medical recommendations is one of the most serious problems in healthcare both in Poland and worldwide. It is estimated that around 50% people with chronic diseases do not take their medication as prescribed. This in turn leads not only to a weakening of the effectiveness of treatment, but even to a worsening of the condition. Estimates suggest that up to 25% of hospital admissions result from non-adherence to the treatment regimen. The problem therefore has not only an individual dimension, but also a social and financial one.

There are many reasons for this. In general terms, they can be divided into those that lie on the side of the patient and those that relate to the doctor's behaviour and competence. Factors related to the functioning of the health care system also play a role. For example, the lack of sufficient time to visit the doctor prevents an effective medical history. There are also various barriers to accessing services in health care, such as: long waiting times for appointments, long distances to health centres, lack of adequate information about available services. All these impediments discourage patients from using services.

Factors influencing non-compliance lying on the side of patients is primarily patients' insufficient or superficial knowledge of health and the associated difficulties in understanding medical information. Many people use only information found on the Internet without being able to assess its reliability or from knowledge obtained from friends. Other factors in this group include lack of understanding of the mechanism and complexity of the disease, insufficient involvement of patients by doctors in treatment decisions, and lack of adequate support from family and others around the patient. More specific factors having a negative impact on adherence to medical recommendations include: the patient's denial of the fact of being ill (especially in the case of asymptomatic diseases), the complexity of the treatment process and complicated drug dosing regimens, the inconvenience or painfulness of side effects of taken drugs or procedures, lack of trust in the attending physician, negative previous experiences in contacts with medical staff, lack of financial resources to purchase prescribed drugs or to pay for ordered diagnostic tests or procedures.

Among the main factors favouring non-compliance with medical recommendations on the side of doctors are primarily their inadequate communication skills, which underlie most of the others, such as not attempting to explain the benefits and side effects of medicines, underestimating the limitations of patients' knowledge or intellectual capacity related to e.g. disease progression or advanced age, lack of effective and timely information exchange between the treating physician and other medical professionals. These factors are compounded by prescribing complex therapies when simpler ones are available, insufficient consideration of the financial and organisational burden (e.g. lack of family support) on the patient.

The situation can certainly be improved by making greater use of technological solutions available today, such as simplified treatment regimens whenever possible (e.g. once-a-day dosing), medication organisers that allow patients to control the timing of different preparations, or combination preparations instead of several simple ones whenever possible and medically justified. Smartphone apps can also be used to remind patients of the times to take their medicines, computerised prescription renewal systems to prevent late reporting to the doctor, or contact via telemedicine tools.

However, a key role in improving adherence to medical recommendations is played primarily by the effective communication between doctor and patient. This communication - like any other - is a two-way process. It involves both speaking and listening by both parties. On the part of doctors, it requires the ability to present medical information clearly, to adapt their statements to the patient's knowledge, sensitivity, emotional and medical state, to avoid specialised terminology where possible, and to explain these terms precisely where necessary. This is because, in their contact with the patient, doctors find themselves in a familiar world of medical knowledge and health care institutions, which may lead them, for example, to underestimate the limitations of the patient's knowledge. Patients, on the other hand, are usually laymen who (especially at the beginning of their illness) find themselves in an unfamiliar situation that they have yet to learn. And most often they have to learn it quickly.

An equally important communication skill for the doctor is listening, and in particular active listening. It involves, among other things, establishing eye contact with the patient, focusing on the patient's statements and summarising them so that the patient can assess whether he/she has been understood as intended, asking open questions (e.g. "Why do you think...", "What could be the reason for..."), asking the patient for additional explanations or information, allowing the patient to speak freely so that he/she can also refer to the non-medical circumstances of the problem he/she is reporting.

It is not difficult to see that effective physician-patient communication that can foster adherence to medical advice is based on partnership relationship. In it, the doctor can take into account the possibility of the patient not complying with the recommendations and guide the conversation in such a way as to minimise this risk. The peer relationship also helps to detect the possible causes of this risk and to remove obstacles to the patient's compliance. The doctor must not judge the patient. His relationship with the patient is based on the recognition of the equality of both parties and on mutual respect. The aim of this relationship is to arrive at a common solution to a medical problem, not to make moral judgements. Judging the patient is not only detrimental to the patient, but usually also counterproductive, as it may discourage the patient from being honest and cooperative with the doctor, and thus may contribute to non-compliance. In a partnership with the patient, the doctor should strive to reach an agreement, treating non-compliance as a common problem and its solution as a prerequisite for effective treatment.

In order to reduce the risk of non-adherence, the doctor must make the patient aware of the seriousness of his or her illness, provide information on the availability of effective treatments and the risks of not starting, interrupting or failing to complete the treatment. To this end, it is essential to check that the patient understands the diagnosis and accepts the proposed treatment. It is best to ask the patient to describe his/her condition in his/her own words, summarise the therapeutic recommendations made to him/her, confirm that he/she accepts the treatment proposed to him/her and that he/she understands the consequences of ineffective treatment, in particular the consequences of not following the agreed course of action. By answering the open-ended questions asked by the doctor for this purpose, the patient has the opportunity to organise the information obtained independently. This makes it clear whether he or she has understood the information and what weight he or she gives to the various elements of knowledge received. It is also necessary to encourage the patient to point out any difficulties he or she may encounter in following the recommendations. The doctor should also reflect together with the patient on the possibilities of overcoming these difficulties.

When identifying potential or actual difficulties in adherence, the doctor should take action to support the patient. Show an understanding of the patient's situation and make a joint attempt to identify the causes. If possible, he/she should also take care to providing support to the patient from family, friends or acquaintances, e.g. by encouraging the patient to invite relatives to the next appointment. It may also be helpful to involve other members of staff at the treatment facility, to provide care and psychological support or to involve relevant institutions.

The communication process between doctor and patient does not always run smoothly and as expected, of course. There are often discrepancies requiring clarification or even conflictswhich need to be resolved. This is achieved primarily by reassuring the patient that these problems are common problems and that the remedies must also be worked out together. This partnership allows the patient to trust the doctor and thus acquire a sense of empowerment. In turn, this significantly increases the likelihood that he or she will comply with the recommendations.

Prof. Dr. Paweł Łuków(Polish philosopher and ethicist, professor of humanities, university teacher)