Who’s Accountable for Adherence?

Some years ago, my whole approach to treating patients changed after a research colleague told me about MEMS caps, the Medication Electronic Monitoring System medicine bottle caps sold by Aardex (www.mwvaardex.com). I immediately asked my research fellow to incorporate the MEMS caps into a study we were doing of a treatment for psoriasis. The findings were transformative. It was suddenly apparent that my patients’ adherence to treatment was miserable. Truly pitiful. Awful.

If you’ve been following this series of articles on adherence, you probably realize that I think that the physician’s relationship with their patient is a key factor driving whether or not patients take their medication. If patients don’t feel their doctor cares about them, they are unlikely to trust the doctor or the medication the doctor prescribes (and they surely don’t trust drug companies, federal regulators or insurers). Assuring that patients perceive that they are seeing a caring doctor is a foundation of successful drug therapy.

Raise Your Expectations

The effect of being perceived as caring is multiplied when patients are also given a sense of accountability to the caring healthcare provider. When there is accountability, patients don’t only trust the caring doctor, they also don’t want to let the doctor down. Instead of fearing the medication, patients may fear feeling embarrassment if they don’t meet the expectations of a physician who cares about them.

This is not rocket science. In your own work, people do things when they are held accountable—all the more so when they are held accountable to people they respect, and again to people who they feel care about them. But can you bottle and sell accountability? I am trying. At the university where I teach, we tested a scalable means of giving acne patients that sense that the doctor cares about them. We tested an online reporting system designed to give patients the sense of accountability.

The system asked patients to report how they were doing each week. In contrast to reminder systems, the accountability engendered by this online reporting approach had a dramatic effect on patients’ treatment outcomes and is marketed to health systems, pharmacies, insurers and pharmaceutical manufacturers as a way to enhance patients’ use of medication (www.causaresearch.com).

It is often said that there is no one ideal way to improve adherence, that to improve adherence we have to address the specific reason, among a host of potential reasons, that the patient isn’t taking his medication. That may be true to some extent, but there are many reasons people don’t do things, and holding them accountable makes them do things, largely irrespective of why they were initially reluctant or whether they were simply lazy. It’s time we held patients more accountable for adherence behaviors.

  • Steven Feldman, M.D.

    Dr. Steven Feldman is Professor of Dermatology and Public Health Sciences at Wake Forest Baptist Medical Center. Steve studies patient adherence at North Carolina’s Wake Forest Baptist Medical Center. He is also Chief Science Officer of Causa Reseach, an adherence solutions company (www.causaresearch.com), founder of www.DrScore.com, and author of “Compartments” and “An Illustrated Dictionary of Behavioral Economics for Healthcare Professionals.”


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