Every two weeks or so, I receive notice of yet another national conference aimed at solving the problem of our wide-scale non-adherence to prescription medications. This makes me cross. Each conference features expert reports about our misbehavior – who doesn't comply with what – and bewails the huge number of us who fail to adhere to the ideal schedule. Then each conference gives plenty of airtime to more experts describing smart pill bottles, apps that nag at us like a mom reminding a fourth grader to make his bed, and how patient communities can provide important information about our drugs since our clinicians rarely do.
Enough with blaming us for our approach to taking our (many) medications.
When clinicians and health systems start to take this issue seriously, such conferences might be useful. Until then, the statistics on non-adherence and efforts to improve our individual behavior are meaningless. Don't bother with the conferences or the interventions.
Before anyone starts fixing us, try fixing these three things.
Clinician prescribing skills: Even with growing recognition of the adherence gap, physicians rarely effectively prescribe medications to patients. What do we need to know? What the medication is called; what it is for; how to take it; how we'll know if it works; what to do about what side effects; who to contact for advice about them, and so on. What plan is in place to make sure we remember all this information after we have asked our questions and they have been answered in a way that we can understand?
Are these skills taught in medical schools? No. Are any board or certification questions asked of new docs or practicing ones – in general or specifically – on this topic? No. Is CME available to teach these skills? No.
From a sheer economy of scale perspective, clinicians should be the starting place for improving medication adherence. If communicating about the appropriate use of medication is not a priority for them, why should using medications as directed be a priority for us?
Medication labels: The pharmaceutical and drug distribution industries should be embarrassed. They have been working on a uniform method of clear communication on bottles, boxes, tubes and inserts since I started working on patient concerns in 1992. Hey – no urgency...
Have you gotten a prescription lately? If you have, you know that these different stakeholders don't have enough stakes in the outcomes for their ultimate users to summon the will to pursue much progress. Any discussion of health literacy should be directed not at us, but rather at the formidable barriers that exist for even the most health literate among us to decipher what the text on the label means and to have access to accompanying printed material that doesn't require a twelfth grade education and a magnifying glass.
Pharmacist availability and focus: Pharmacists can be worth pure gold in helping us understand how to make good use of our medications. Right now they are shielded from us by thoughtless "check this box" requirements (the small print that says you refuse counseling from this pharmacist), lack of availability and lack of privacy in most settings.
One rainy winter night in a pharmacy near the Seattle airport, I heard a gentle but persistent pharmacist counsel every person to whom he dispensed pediatric medications or antibiotics about the size of a teaspoon or dose, why it was important to take the medication for however long and invite them to come back if they had questions. Brilliant. Public health hero. Only problem? I sat there for two hours waiting for my prescription and I heard every word he and his customers uttered.
How many people walk out the door having paid for medications they don't know how to use correctly because they don't know they can ask for advice? Or they are too embarrassed to do so in front of an audience of fellow customers? Or maybe they're not willing to wait another 45 minutes for the busy pharmacist to tear herself away from pill-dispensing?
Yes, many of us – including me – struggle to take our multiple medications every day at the appropriate time with the appropriate contents in our bellies. Those of us who say we don't struggle are kidding. We struggle in many different ways for many different reasons: "Left my pills at home," "I couldn't find anything to drink/eat," "I was on the bus and forgot," "Can't afford 'em"... whatever the case may be. But all of us have in common these three experiences:
- We don't get complete information from our clinicians about why our medications are important and how to take them over time.
- Information about use of those medications is incomprehensible and often unavailable (online and off) to many of us.
- We lack easy access to counseling from our busy pharmacist.
Fix these, then let's talk about finding out just how big the problem of medication adherence is in this country. That is when efforts can be targeted toward what we can do to make better use of the medications we hope will end our suffering and save our lives.