SELF HELP: Patients must also do their best to prevent asthma attacks

A conscientious allergist I know refuses to treat patients with asthma who don’t follow his recommendations for keeping flare-ups at bay with preventive medication. “I don’t want anyone dying on my watch,” he explains. “I’d rather devote my time to patients who do their best to prevent asthma attacks.”

Noncompliance ? or, as some health practitioners prefer, non-adherence ? to medical prescriptions is a problem of enormous proportions that often results in recurring or persistent illness, excessive tests and avoidable hospitalisations that increase the cost of medical care. Failure to follow doctors’ orders can even result in death, as happened to one woman who suffered for years with chronic pain. She finally found a doctor who prescribed methadone, with directions to take one pill four times a day. But suffering severely, she started with two pills, then two hours later took a third, and later a fourth, hoping it would help her sleep. She never woke up.

For a host of reasons, at least half of patients fail to comply with the treatments their doctors prescribe. Dr. Edward C. Rosenow III of the Mayo Clinic College of Medicine calls compliance “the sixth vital sign,” as important as respiration, heart rate, temperature, blood pressure and pain in evaluating a patient’s medical status.

In most cases, the problem revolves around a failure to take medication as prescribed. This can mean taking too much of a drug as well as too little or none at all. The misuse or non-use of prescribed medications is estimated to add nearly $200 billion a year to the cost of medical care.

The reasons for non-compliance are many and are often complex. The fault may lie with the patient, the doctor or the circumstances under which care is delivered. For example, under the stress of a medical visit, patients may not fully register what a doctor tells them or may quickly forget, especially if it involves doing something ? like changing their diets, stopping smoking or adopting an exercise program ? that they really don’t want to do or would have difficulty fitting into their lives. I understand such resistance. I had a prescription for a blood test for three months before I had it done; in that time I took a chance that the medication I was taking for back pain was destroying my liver. There were two reasons for my delay: I didn’t have the time to sit for hours in a lab waiting my turn, and I didn’t want to find out that I might have to stop the medication.

One of the most important factors in patient non-compliance is poor communication by doctors, Rosenow wrote in The Mayo Clinic Proceedings last summer. Doctors pressed to care for too many patients in the time available may fail to explain adequately the reasons for their recommendations and drug prescriptions, the possible side effects and what to do about them, and the potential consequences of not following the prescribed remedy or preventive.

The problem of understanding the doctor’s prescription is magnified by language and cultural barriers. The doctor says one thing but the patient, perhaps interpreting what is said within different cultural parameters, hears another. An extreme case of this medical divide is brilliantly documented in one of the best books I’ve ever read: The Spirit Catches You and You Fall Down by Anne Fadiman. It is a harrowing tale of an immigrant Hmong family with an epileptic child who is poorly treated and dies because the family’s belief system was not taken into account by the doctors who cared for her.

Patients being treated for chronic diseases, especially diseases without apparent symptoms, like hypertension and diabetes, are particularly prone to non-compliance. Patients with chronic conditions often stop taking prescribed medications after about six months of therapy.

Rosenow suggests that “the physician, a trained registered nurse or a health educator needs to spend time explaining the nature of the disease(s) and why he or she has selected the specific medications, even though the patient may be asymptomatic”. Patients also often fail to tell their doctors that they are not taking a drug as prescribed ? and may even lie when asked, prompting the doctor to order more tests or prescribe an even more challenging remedy, thinking that the first prescription is not working.

Patients with relapsing disorders, like chronic reflux disease, tend to stop their medications when they feel well, only to invite a recurrence that could cause irreparable damage to the esophagus or other organs. Likewise for mental disorders like depression. Among those treated with antidepressants, nearly half discontinue the drugs after a year because they feel better, but a fourth of those don’t tell their doctors.

With asthma, proper use of a metered-dose inhaler can prevent more than 75 per cent of flare-ups, but fewer than half are taught how to use the inhaler correctly and, although their doctors don’t realise it, some patients are physically incapable of using the inhaler as intended.

But even when properly instructed, patients often fail to use the inhaler, especially if the patient is a child. I recently heard the mother of a child with asthma say, “I don’t like treating him with all those steroids.” Did anyone ever tell her about the risks of not treating him? Patients with infections often stop taking prescribed antibiotics as soon as they feel better, inviting a relapse or the emergence of antibiotic-resistant bacteria. When patients are non-compliant in this way, doctors can prescribe an antibiotic that is completed faster.

NYTNS