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Wednesday Oct 01, 2014

Make It Easy: Convenient Communication Can Boost Patient Adherence

We've all experienced the frustration of caring for a patient who doesn't do what's best for his or her health.

"Why won't he (or she) just take his (or her) medications?!" we frequently vent behind closed doors (and on blogs). As family physicians, we want the best for our patients, even when they seemingly don't want the same for themselves.

© 2014 Tara Higgins/Fosse Photography

My mentors taught me to be a good listener and to speak in layman's terms, saying it was the best way to "connect" with patients. These skills are essential, but sometimes they're not enough to move our patients to take sustained action. As a resident, I believed that if I just explained things well enough, my stubborn patients would finally start taking my advice. But often my honed pitch and elegant napkin diagrams were forgotten within a few days.

I would ask my patients, "Why didn't you call us when your blood sugars were above 300 every day for the past three months?" The conclusions of their responses varied, but the beginnings were usually along the lines of, "It was just too hard because … "

These excuses angered me. I was trying my hardest; why couldn't they? At the end of a long clinic day, I felt like Lloyd Christmas from the movie Dumb and Dumber (except it was my patient's feet falling off instead of a parakeet's head).

The systemic effects of nonadherence have been recognized for many years. Organizations and policymakers have promoted a myriad of remedies in the hope they would prove effective, but they often seem incompatible with our daily clinic grind. In fact, many of these "fixes" become a source of frustration themselves and further distance us from patients.

Thankfully, we have started to move away from the paternalistic approach that has long dominated our interaction with patients. "Patient engagement" is the new catchphrase, but what does that look like in action? How do we truly partner with patients? How can we get difficult patients to take responsibility and stop making unhealthy decisions? Is it even possible in our dysfunctional, rushed system with its 10-minute office visits?

I started a direct primary care practice nearly three years ago, and it gave me an opportunity to think about delivering care without the usual constraints. My membership-based pricing allowed for creativity in many things, including patient communications.

One of my primary goals was to make care less of a hassle. Communicating by any reasonable channel, including email and text message, was one of our selling points. (And yes, this is allowed under the Health Insurance Portability and Accountability Act given permission and appropriate safeguards.) Of course, there was business incentive to offer such access, but the clinical effect became evident early on.

One of my first patients, who I'll call John, joined my new practice at the behest of his wife a few days after being discharged from the hospital for transient ischemic attacks and hypertensive urgency. He had been inconsistent in taking his meds since being diagnosed, despite having regular contact with primary care and cardiology, as well as a personal escort (his wife) to all visits. Being a typical middle-aged man, he wasn't a fan of doctors and let me know that upfront.

Our first visit lasted nearly an hour. The risk of stroke and disability were clearly understood, but scare tactics had failed in the past. He said that medications were "fine" with him, but busy days running a small business caused him to miss doses occasionally and also had led him to delay picking up refills for prolonged periods.

I explained I'd like an update on his home blood pressure readings within one or two weeks and that he could email or text us anytime with numbers or concerns. Although he was agreeable, his wife and I were both skeptical he'd stick with the plan.

Much to my surprise, he emailed about a week after that initial visit. His BPs were nearly at goal, but he reported some "bedroom performance issues." He suspected his meds were to blame. He failed to mention this problem to any of his physicians previously but had gotten some "Mexican Viagra" from a friend in the past.

His beta-blocker, metoprolol, could likely be contributing to the problem. I suggested trying an alternative antihypertensive in his regimen. He texted me about two weeks later reporting he felt like he was 25 again, his blood pressure was at target and he needed prescription refills. Was I a genius for recognizing that a common beta-blocker adverse drug reaction prevented adherence? No. In fact, I failed to inquire about the common issue during an hourlong visit.

John has now had well-controlled hypertension for more than two years and no further ER visits or hospitalizations. He likely wouldn't be able to define "patient engagement" if asked, and I didn't need Jedi mind tricks to engage him. I was available and convenient; and sometimes that makes all the difference.

Ryan Neuhofel, D.O., M.P.H., owns a direct primary care practice in Lawrence, Kan. You can follow him on Twitter @NeuCare.

Posted at 01:17PM Oct 01, 2014 by Ryan Neuhofel

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