We have a critical last-mile problem in the healthcare industry: getting from a doctor’s prescription to a patient regularly taking her medication. The “last-mile problem” usually refers to the challenge of laying the final stretch of wire or cable to each individual home when providing telephone or internet service. Healthcare has its own last-mile problem that is approximately the distance from the medicine cabinet to the patient’s mouth. And the fundamental cause is inadequate patient-physician communication.
This doesn’t seem like a complex problem, but the numbers are astounding: about 50% of medications are taken as prescribed. That’s right: the simple, sad math is that about half of patients don’t succeed in taking their medications as prescribed. Given that medications are generally key treatments for our deadliest conditions such as diabetes, heart disease, and asthma; and given that half the time the medication is not making it from the prescription pad to the patient’s mouth, you would expect that we would be working very hard to solve this problem. To suggest otherwise would imply an unconscionable amount of waste, missed opportunity, and needless lives lost.
It turns out that in 2008, there were more studies published just about acid reflux disease (GERD) than there were about medication compliance. Why such a disconnect? Let’s reflect on my medical training. In my seven years of medical school and residency — that’s about 20,000 hours of training — I spent approximately one hour learning about medication compliance, and about 45 minutes of that was talking about all the complications caused by those non-compliant, non-adherent, patients who failed to follow through on doctors’ orders. This is not a failure on the part of the patient, it is a failure of patient-physician communication.
We doctors need to accept our share of responsibility for successfully taken medicines. The fatal flaw is thinking that our responsibility as health care providers ends when we hand the correct prescription to the patient. A corollary is that the vast majority of our research investment is targeted only at getting drugs from discovery to the point of prescription. Here are just a few points downstream from there where we can fail:
– the patient doesn’t understand why he should take the medicine, so he doesn’t
– she is experiencing a side effect, or is afraid of experiencing one
– he can’t afford the medicine, and is embarrassed to tell the physician
– she doesn’t think the medication is helping, so she stops taking it
To be sure, there are other points of failure, but the ones above are common and they have something in common: they all result from inadequate patient-physician communication. Especially among the tens of millions in the U.S. taking multiple medications, many don’t even know why they are taking a given medication. Personally, I think I have failed if one of my patients doesn’t know the purpose of each of her medications. In fact, I try to include the reason for taking the medication as part of the prescription, e.g., “Atenolol 50 mg tablets, take one by mouth every day for high blood pressure.” But the explanation “for high blood pressure” is rarely included in a prescription. In my experience, over 99% of prescriptions handed to patients and printed on the medication bottle fail to include this basic guidance on what the medication is supposed to treat. Why? Because we think our job is done when we figure out what drug to prescribe. Because we are too busy or too lazy. Because the reason for taking the drug is not a required part of the prescription! Now that seems like low-hanging fruit in health care reform.
And let’s not forget to talk to each other. At every doctor visit, the patient and doctor should review the patients’ current medication list (this actually is explicitly recommended by the leading hospital certification organization). Doctors: let’s make sure this discussion includes the patients’ understanding of what each medicine is for, and an invitation to share any questions, doubts, or concerns. It’s amazing what we learn if we simply ask. Patients: this is YOUR health. Don’t leave the doctors’ office until your questions are answered and you understand the plan. Lawmakers: we should require prescriptions to include the reason for taking the medicine, and we should give doctors financial incentives not just when they prescribe the right medicines, but when their patients actually take them. And finally, innovators: as we create novel treatments, let’s not forget the millions of lives and billions of dollars we can save by innovating on the process of getting those prescriptions taken as prescribed.
** Disclaimer: The views expressed here are mine alone and not those of my employer. **