Concordance in Medical Consultations

A Critical Review

Kristian Pollock

• Publisher: CRC Press
• Year: 2018
• eBook ISBN: 9781315357324
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The capacity of professional medicine to resist change - and also concordance - is impressive, but perplexing. It is one of the issues I seek to address in this book. I suggest that a preoccupation with trying to change the relationship between the professional-patient dyad has deflected attention from the extent to which such relations are embedded in, and constrained by, wider administrative and organisational structures, especially as these relate to the operation of professional hierarchies and interprofessional deference and allegiances. Barriers to change also result from the inertia of a system which has evolved a highly stylised etiquette as an adaptive mechanism to contain the difficulties and tensions intrinsic to the medical consultation. Its therapeutic purpose and potential are often subordinate to the goal of achieving success as a social encounter. The principles of concordance are deeply challenging to traditional professional roles and status. However, medicine has always displayed an ability to block change through tactics of appropriation and incorporation. Professionals have often shown particular difficulty giving up their monopoly of 'expertise' and in acknowledging the legitimacy of the patient perspective. Although the term 'concordance' has become quite widely used, its meaning is usually subverted by its employment as a synonym for 'compliance', albeit 'informed' compliance. A slightly more sophisticated version values professional elicitation of the patient perspective in order to more accurately tailor information as a means of overcoming the unhelpful m/sconceptions that impede compliance. The original emphasis on the consultation as a negotiated exchange, in which the professional has something of value to learn from the patient, has largely been lost. The rhetoric of modernity and change provides an effective mask for inertia and conservatism. Preface.

Chapter One

Introduction

Within the field of healthcare the terms ‘compliance’ and ‘non-compliance’ refer to the extent to which patients follow (or not) the regimens recommended by their doctors. An enormous amount of research over several decades has shown consistently that between one third and one half of patients do not follow their doctors’ advice and in particular fail to take the medicines prescribed for them (Carter, Taylor & Levenson 2003; Donovan 1995; Donovan & Blake 1992; Haynes & Sackett 1979; Sackett & Haynes 1976; Stimson 1974; Trostle 1998). The manifest failure of so many patients to act in their own best interests has baffled the medical establishment. No distinctive characteristics of non-compliant individuals have been established, and the range of illnesses eliciting non-compliant behaviour runs across the spectrum from trivial to life-threatening. In one study Rovelli etal. found that patient non-compliance with immunosuppressive drugs following organ transplant caused a higher incidence of graft loss than uncontrollable rejection affecting patients who had adhered to treatment as prescribed. Eighteen per cent of renal transplant patients were found to be non-compliant with treatment and the majority (91%) of these subsequently experienced either organ rejection or death. The comparable failure rate for compliant patients was 18% (Rovelli et al. 1989). The high rates of ‘non-compliance’ among AIDS patients have also been well established (Chesney, Morin & Sherr 2002; Wright 2000). Thousands of studies of non-compliance and how to modify patient behaviour have been conducted over the last three decades. However, this enormous effort has made no discernible impact on the consistently high rates of reported non-adherence. The mismatch between medical prescription and patient behaviour has persisted, and manifests itself in many different forms (Box 1.1).

Box 1.1 Some types of ‘non-compliant’ behaviour

• •   Not taking a prescribed medicine
• •   Taking a higher dose of the medicine than was prescribed
• •   Taking less than the prescribed dose
• •   Taking the medicine more often than prescribed
• •   Taking the medicine less often than prescribed
• •   Taking ‘drug holidays’ from time to time
• •   Modifying treatment to accommodate other activities, such as work and social activities (e.g. missing a dose before social drinking)
• •   Stopping the medicine without finishing the course
• •   Not getting the prescription made up
• •   Taking additional medicines (Over the counter (OTC) or Prescription on ly medicines (POM))
• •   Continuing with behaviours (e.g. relating to diet, alcohol, smoking) against medical advice
• •   A combination of any of the above

Non-compliance clearly has enormous significance for the healthcare system. As health policy is increasingly driven by cost containment strategies attention has focused on the need to reduce wasted and inappropriate expenditure. The widespread failure of many patients to take their medicines as prescribed – or even at all – constitutes a huge squandering of effort and resources. It subverts the aim of professional treatment and is also a major source of suboptimal health outcomes. In a climate of medical practice dominated by the principles and self-evident rationality of Evidence-Based Medicine, the failure of large numbers of patients to take prescribed medicines appears both inexplicable and intolerable.

In 1995 the Royal Pharmaceutical Society of Great Britain undertook an investigation of non-compliance, with a view to developing practical recommendations for improving medicine taking among patients. This inquiry led in an unanticipated direction, and resulted in the usefulness of the concept of compliance being seriously questioned. In 1997 it published a report, From Compliance to Concordance, in which the concept of ‘concordance’ was advocated as a tool for radically changing the culture of prescribing and the substance of the relationship between health professionals and patients (RPSGB 1997). The members of the working party had consulted widely in the course of their investigations. However, in developing the concept of concordance, the discussions that were held with groups of patients and patient representatives were held to be particularly significant (Marinker 1997; Marinker 2004).

Concordance opens up the problem of non-compliance by explicitly recognising and valuing the patient perspective in medicine taking, rather than confining consideration of the issue to a narrow focus on medical values and rationality. Successful medicine taking rests on an agreement between professional and patient, and a mutual understanding of the different concerns and goals of treatment. The competence of the patient is acknowledged, along with the legitimacy of his beliefs and preferences in relation to healthcare, even where these differ from those of the professional. Ideally, differences between these perspectives would be resolved through negotiated consensus. However, it is accepted that, in all ordinary circumstances, the final decision about treatment rests with the patient.

The outcome of a concordant consultation may be that patient and practitioner disagree about the best course of action. A concordant consultation does not mean that the health professional is under any obligation to practise ‘bad medicine’, or accede to requests from patients that he considers to be unreasonable or inappropriate. In an ideal encounter, however, both parties would be aware of, and able to understand, the other’s reasons for adhering to a different position, and perhaps be able to achieve a degree of compromise or negotiated consensus. In the common scenario where there is a range of options to be considered, there is scope for patient choice of treatment. Where patients are encouraged to state their preferences, and to actively participate in the process of decision making about illness management, it is assumed that they are more likely to be committed to the treatment which follows from this. Accepting the patient’s choice of treatment, even though this may not be the preferred option from the professional point of view, may produce a better therapeutic gain if it results in treatment being accepted rather than rejected. The prescription of medicines which are unwanted or unused should be substantially reduced, with a consequent reduction in avoidable cost. Equally as significant, patients’ experience of medical encounters and the quality of service provision should be improved. In the concordant model, this is taken to be a valid outcome of healthcare.

Concordance can be regarded as an extension of the principles of patient centred medicine, particularly as these are applied to the activities of medicine taking and prescribing. Patient-centred medicine is central to the articulation of government health policy (Department of Health 1991, 1996, 1999, 2000, 2001, 2002). A more responsive and user-driven service is seen as a means to the development of a more cost-effective, socially accountable and higher quality health service. The emphasis on the satisfaction of individual needs and aspirations accords with the primacy of individual autonomy as a value within the system of corporate industrialism of the modern state. Concordance, like compliance, has a social history. The following chapters trace the development of both concepts, in the context of the major influences exerted from outside medicine as well as within it, before making an assessment of the present and future contribution of concordance to the practice of healthcare.

References

Carter S, Taylor D and Levenson R (2003) A Question of Choice – compliance in medicine taking: a preliminary review. Medicines Partnership, London.

Chesney MA, Morin M and Sherr L (2002) Adherence to HIV combination therapy. Social Science and Medicine. 50: 1599–1605.

Department of Health (1991) The Patient’s Charter. Department of Health, London.

Department of Health (1996) Patient Partnership: building a collaborative strategy. Department of Health, National Health Service Executive, London.

Department of Health (1999) Patient and Public Involvement in the New NHS. Department of Health, London.

Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform. Department of Health, London.

Department of Health (2001) The Expert Patient: a new approach to chronic disease management for the 21st century. Department of Health, London.

Department of Health (2002) Learning from Bristol: the DH response to the report of the public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984–1995. Department of Health, London.

Donovan J (1995) Patient decision making: the missing ingredient in compliance research. International Journal of Technology Assessment in Health Care. 11: 443–55.

Donovan J and Blake D (1992) Patient non-compliance: deviance or reasoned decision making? Social Science and Medicine. 35(5): 507–13.

Haynes RB and Sackett DL (1979) Compliance in Health Care. Johns Hopkins University Press, Baltimore.

Marinker M (1997) Writing prescriptions is easy. BMJ. 314: 747–8.

Marinker M (2004) From compliance to concordance: a personal view. In: C Bond (ed.) Concordance: a partnership in medicine-taking. Pharmaceutical Press, London, pp. 1–7.

Rovelli M, Palmeri D, Vossler E, Bartus S, Hull D and Schweizer R (1989) Noncompliance in organ transplant patients. Transplantation Proceedings. 21(1): 833–4.

RPSGB (1997) From Compliance to Concordance: achieving shared goals in medicine taking. RPSGB, London.

Sackett DL and Haynes R (1976) Compliance with Therapeutic Regimes. Johns Hopkins University Press, Baltimore.

Stimson G (1974) Obeying doctor’s orders: a view from the other side. Social Science and Medicine. 8: 97–104.

Trostle JA (1998) Medical compliance as an ideology. Social Science and Medicine. 27: 1299–308.

Wright M (2000) The old problem of adherence: research on treatment adherence and its relevance for HIV/AIDS. Aids Care. 12: 703–10.

Chapter Two

The medical construction of compliance

The failure of patients to take medicines as prescribed by their physician appears to be longstanding. Hippocrates is reported to have cautioned physicians against accepting the accuracy of patients’ reported compliance (Trostle 1988: 1300). There is evidence that professional concern with non-compliance predates the mid-twentieth century development of a truly effective pharmacopoeia. From the mid-nineteenth century, medical concern over control of patient behaviour and medicine taking was bound up with the consolidation of professional authority and the development of commercial interests and predated the discovery of effective treatments (Freidson 1970; Schwartz, Soumeris & Ajorn 1989; Trostle 1998). In the early decades of the twentieth century, the profession successfully appropriated control over access to infant feeding formula and nutritional supplements and the information given to mothers about how to use it. This illustrates the growing concern of doctors to influence the health-related behaviours of the lay population, and acquire control over access to information. It was also an early instance of the development of compliance as a marketing device by the pharmaceutical companies (Trostle 1998). Lerner (1997) describes the censorious medical response to TB patients after the First World War who failed to cooperate with what treatment was available, and discharged themselves prematurely from hospital in large numbers. However, the availability from the 1940s of the sulphonamides and antibiotics, and thereafter a...

Table of contents

• Cover
• Title Page
• Copyright Page
• Dedication Page
• Table of Contents
• Preface
• About the author
• Acknowledgements
• 1 Introduction
• 2 The medical construction of compliance
• 3 Evidence-based medicine
• 4 The lay perspective
• 5 The doctor-patient relationship
• 6 The medical consultation
• 7 Patient participation and shared decision making in the consultation
• 8 The informed and expert patient
• 9 Satisfaction
• 10 Conclusion
• Index