Enhancing Patients’ Treatment Adherence

Getting patients to take medications is not altogether different from every other aspect of getting other people to do things.  Our entire society is built on cooperation, on people taking actions at the behest of others.  Society has rules, regulations, incentives and disincentives that are intended to drive desired behaviors.  Sometimes the directives are quite effective, while at other times, they fail miserably.

Whatever the setting—education, business, or medicine—holding people accountable is one of the primary means for assuring people act in ways desired by others.  Holding people accountable for their action happens over and over again in day-to-day activities.  Often, accountability occurs in a directive fashion: a teacher checks that assignments are turned in on time, a supervisor checks the progress of an employees work, a doctor examines how many pills are left in a bottle.  This form of directive accountability is pervasive, can, at least at times, be very effective, and is certainly necessary in many situations.

There is a more informal form of accountability that has even more potent effect on people’s motivation.  It involves people’s sense of self and their involvement in the culture around them.  This form of accountability drives people to excel in their work, to participate in charitable activities, and, potentially, to drive their adherence to medical treatment.   

Already, cultural accountability has been used in group settings to help obese patients gain control of their weight, to help patients with diabetes manage their blood sugar.  We think of using the cultural accountability of groups to help motivate patients in the most adherence challenging situations, when complex lifestyle modification is needed. 

We could use cultural accountability more often to help patients take their daily pills.  Just as changes in our culture have promoted a reduction in smoking behavior (another extraordinary adherence challenge), we could create a culture in which adherence behavior is expected from people.  Even if we can’t immediately implement this change in society, we could do a better job implementing it at the level of our own practices—with our words, with signs & brochures, with email messaging— creating a feeling among our patients that they and their adherence behaviors are an integral part of the effort to improve the health of not just themselves but of the whole group of people being cared for by the practice.

–Steven R Feldman MD PhD