In the April issue of PM360, I discussed the overall issues and problems with patient adherence. In Part II of this series, I want to address some of the reasons for non-adherence and how doctors can overcome them. Perhaps the number one reason for poor adherence is that patients forget to take their medicine. I call this the “Pavlov’s Dog problem.” People go about their day doing routine things without even thinking about them. You can probably relate.

Each weekday morning, I leave my driveway and turn left to go to work. On Saturday mornings, I take my son to Tae Kwon Do class, which means I should turn right out of my driveway. But all too often, I turn left without even thinking about it. Unless taking medication is a habit that doesn’t require thought, it is likely to be missed. Fears are a big issue in poor adherence. While some patients may like the idea of taking some medication internally, others are afraid of the same prospect. Indeed, many of my patients are terrified of even putting a medication on the skin, much less taking one internally.

Fortunately, getting past fears is not an insurmountable task. (We’ll discuss this in an upcoming issue.) The key is making sure the patient trusts the doctor. One of the most intriguing aspects of adherence behavior is its unpredictability. For some patients reminders may encourage better use of medication. With other patients, reminders reduce adherence.

Some years ago, my colleagues and I enrolled teenagers with acne into a study of adherence to a once-a-day topical benzoyl peroxide product. The teens were randomized into four groups. The first group received the standard of care treatment, with return visits at 6 and 12 weeks; and was just so-so in their use of the treatment. The second group was seen more frequently—as might be done in a clinical trial—with return visits at weeks 1, 2, 4, 6, 8 and 12 weeks. Those teens used the medication more often. We called members of the third group daily, but that didn’t seem to make adherence any better than the standard of care, no reminder group. For the fourth group, we called the teenagers’ parents every day and told them, “Don’t forget! Remind your child to use the medication.” That group of teenagers used the medication less than did the teenagers in the other three groups.

Teenage psychology is a world in itself. (Note that this phenomenon is not just common in teenagers. If the trashcan is full in my kitchen, I’ll take out the garbage. But if I hear my wife nagging me to do it, I won’t. She can’t make me.) Along these same lines, you might think that having a disease will make people take their medication. It doesn’t.

In fact, the worse the quality of life associated with a chronic illness often the worse is the adherence. It’s as though the mind doesn’t want to think about the disease, so the mind doesn’t think about the treatment either. You might also think that having multiple caregivers in a home, a mother and a father for example, might improve adherence to treatment of chronic disease of children. While it might some of the time, other times the mom may think the dad is administering the medication, while the dad may think the mom is giving the drug. There are way too many reasons why patients don’t take their medications (see list), but do not lose all hope.

There’s one thing that can be done that can address many of these issues all in one swoop, and we’ll discuss it in the next column in the August issue.




  • 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 (, founder of, and author of “Compartments” and “An Illustrated Dictionary of Behavioral Economics for Healthcare Professionals.”


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