On The Road Again

Barring (more) unforeseen events, da boyz and I should be moving to a new domicile in early September.

That means the next 2-3 weeks will be filled with the joys of packing, moving, discontinuing utilities at one site and starting them at another, sending change of address cards, …

Which means, in turn, that posting may be rare for a while.

But I will be thinking of you.

Credit Due Department
Photo: Moving The Cottage RaeA at Flickr

• Looking At Patient Compliance From Both Sides Now
• EnrichMap and Emap Profile Now Online
• Posting Suspended
• Patient Compliance Subverted By The Temptation Of Now
• Nonadherence To Posting Schedule

Zuri - Medication Reminder and Compliance Recorder

An article in today’s (August 19, 2008) Wall Street Journal, Tools Help Patients Interface With Doctors By Victoria E. Knight, opens with this excerpt, a success story about the Zuri, an electronic medication reminder and compliance recorder still in beta:

The article goes on to extol the virtues and promise of

In oversimplified terms, both Intel’s Health Guide and Microsoft’s HealthVault store, organize, analyze, and distribute a variety of healthcare data gathered from a wide array of sources.

The Evolution Of The User Interface In Healthcare Technology

On reading the WSJ article, my first response was - well, OK, my first response was “Where do you sign up to have the WSJ open an article with five paragraphs of a success story featuring your business’s product?”

My very next thought, however, was that the user interface of these gizmos is likely to evolve as have other technological marvels, such as the automobile and the computer. The extent to which new tools are put into use by the population, however obvious their value, is limited by the difficulty, expense, and unfamiliarity of that tool.

In other words, what are the chances my Aunt Hazel from Broken Arrow, Oklahoma will find the Zumi a must-have healthcare device as long as it is a $200 pseudo-iPod with a $40 per month fee that technicians have to set up?

Of course, Aunt Hazel wasn’t interested in driving a car until automatic transmissions became widely available and her best friend began driving her own Ford.

I suspect the the responses by patients to the instruments like the Zuri fall into one of three broad classes:

1. Patients like Ms Shah who have the right problem, the right circumstance, and the right perspective to embrace and use the tool as is, right off the shelf.²
2. Patients who mistrust and are adamantly resistant to (choose one or more) electronics, doctors, healthcare recommendations, sharing personal information, …
3. Patients, like Aunt Hazel, who won’t use a medical tool like the Zuri until it is easier, cheaper, more well known, …

Group #1 is on board already. Group #2 is unlikely to buy into the process regardless of logic, persuasion, or receiving lottery tickets as incentives. But Aunt Hazel’s group? That’s where the action is. Make those electronic whizbangs less intimidating, less difficult, and less expensive.

Then, ask Aunt Hazel to try it out.

Footnotes

1. The quotation marks enclosing self-care are the work of the WSJ folks, and, no, I don’t know the rationale for this punctuation practice. [back]
2. It isn’t clear that if Ms Shah was charged for the Zuri’s use or if it is offered free while still in beta. An out of pocket cost of $240 to enhance compliance of a 3 week course of treatment might have rendered the Zuri less attractive to Ms Shah [back]

• Leviticus & Patient Compliance
• Coaching Patient Compliance
• Patient Compliance Commemoratives
• Bandolier On Patient Compliance
• Patient Compliance With New Medications

Statue of hospital benefactor, Michael Reese,
located in front of Main Reese Building

The Rise and Fall Of Michael Reese Hospital

Although this post does not center on patient compliance, I thought that, given the high proportion of medical professionals among AlignMap’s readers, there may be some interested in the thoughts and memories occasioned by the impending demise of Michael Reese Hospital

A stellar healthcare institution, a prime example of the Jewish mission to care for the sick, and a linchpin of Chicago’s South Side throughout most of the 20th Century, Reese was also the home of my psychiatric residency in the 1970s. The Psychosomatic and Psychiatric Institute at Michael Reese Hospital, its outpatient facility, Wexler Pavilion, and the long time Chair of Psychiatry at Reese, Roy Grinker, MD, in fact, comprise one focus of the essay.

I was fortunate to discover and receive permission to use an outstanding set of photos of the Michael Reese Hospital campus,¹ taken by Lee Bey, who authors Lee Bey: The Urban Observer, a blog which focuses on community and architectural elements of Chicago. I urge viewers to at least check these shots of the Hospital buildings, soon to be replaced by the Olympic Village that is part of Chicago’s bid for the 2016 Games.

These impressive photos, a brief account of Reese’s history, its contributions to medical science, and the role it played in its Chicago community, and my perspective on that once great, irreducibly humanitarian, vitally flawed medical center can be found at

Footnotes

1. Those photos by Lee Bey include the photograph of the statue of Michael Reese seen at the beginning of this post. [back]

• Strategies To Increase Adherence To Antabuse
• Adherence To Treatment: Tips To Patients
• Another Approach To Compliance
• Increasing Sensitivity To Noncompliance
• Using Empathy To Prevent Noncompliance

This excerpt from the New York Times article, Los Angeles Stages a Fast Food Intervention,¹ not only describes the latest example of a government taking action to nudge its citizens toward better nutrition but also succinctly summarizes analogous efforts in the recent past:²

I especially admire the wording of the fundamental issue,

I don’t have an answer, but I am convinced that the preceding question, adjusted for other healthcare issues, deserves far more attention on a national scale.

Until a consensus is reached, the determining factor in such decisions defaults, it seems, all too often to the individual or group who has become invested in a cause to the point of promoting - or coercing - that program. For example, consider Arkansas Governor Mike Huckabee’s interest in passing regulations to halt obesity that was triggered by his personal 100 pound weight loss.³ His efforts may be well intentioned and the resulting laws and resolutions may even be good policy, but depending on the enthusiasms, prejudices, and political motivations of powerful leaders hardly makes for an organized approach to the underlying problems.

And, until a means of distinguishing between personal choice and public health concern is reached, dietary regulations, restrictions on tobacco and alcohol use, mandated mental health treatment, directly observed TB therapy, … will continue to be passed and enforced erratically. And, it will continue to be difficult to provide a scientific explanation why, for example, banning trans-fats is viewed as an acceptable exercise of government while no one appears to be pushing obligatory exercise.

Finally, how about this scenario: The newly elected Governor of Illinois, desperate to keep his campaign promises to hold down state healthcare costs stumbles across the AlignMap web page outlining the costs of medication noncompliance. The Governor checks with the Director of Public Health who explains that the state has long passed laws and regulations regarding, for example, treatment of communicable diseases, including mandated, observed treatment for some disorders. The Governor extends this principle in a bill that mandates total treatment compliance for all patients covered by state run or managed programs under penalty of permanent disbarment from the program. By tying the compliance regulation to anticipated improved health for those covered, the Governor cowes the legislature into passing the bill.

Scary, eh?

On the other hand, as long as we continue the hodge-podge sysemn (or lack of system) now in place, we certainly don’t have to worry about those nasty hobgoblins of consistency (whether foolish or not)

Credit Due Department: The hobgolblin pictured above, I find belatedly, is employed, when not illustrating Emersonian expressions, as mascot for The Wychwood Brewery, producers of Hobgoblin Ale.

Footnotes

1. Los Angeles Stages a Fast Food Intervention by Kim Severson, New York Times August 13, 2008 [back]
2. OK, I’m disappointed that the list didn’t include Chicago’s recently overturned foie gras ban, but otherwise it’s a representative listing [back]
3. See Schools, Healthcare, & Dietary Regulations [back]

• Schools, Healthcare, & Dietary Regulations
• Public Health Vs Informed Consent
• TV Fiction As Public Health Instruction And Motivation
• ADD Medication Adherence: Cultural Changes & Individual Attitudinal Shifts
• Learning From Patient Noncompliance

Not These Rules

These Rules

Dr Rob at Musings of a Distractible Mind offers rules (recommendations, really) to improve the effectiveness of doctors and patients working together. I’ve excerpted one rule from each group to give a flavor of the others.

The only comment I’ll add is that I am more cynical than Dr Rob and have less faith in the power of logic and common sense to change ingrained behavior. Some patients, for example, I believe are psychologically unable to trust anyone, including their doctors. Regardless of the benefit they might derive from doing so, some folks are not able to follow the axioms to trust their doctors and be honest with them. And doctors are hardly immune from the same psychological forces. Nonetheless, I find Dr Rob’s Rules commendable in general and, if followed, capable of impressively reducing noncompliance.

Getting along: Part 1 - Doctor Rules
Excerpt:

Getting along: Part 2 - Patient Rules

Excerpt

• Helping Patients Help Their Doctors
• Welcome To Australian Rules Medication Compliance
• HIV Patients Less Informed
• Managing Noncompliant Patients
• Compliance In Older Patients

The Obligatory Statistical Introduction Waiver

Has anyone read a patient compliance review article that didn’t open with 5-10 seemingly randomly selected statistics indicating the pervasiveness, extent, and negative consequences of noncompliance, including but assuredly not limited to percentage of noncompliance in various patient populations, frequency of noncompliance when it’s a mater of life or death, costs of clinical care, losses in productivity, number of unnecessary outpatient visits and hospital and nursing home admissions, … ?

Has anyone read a patient compliance review article that opened with “Noncompliance with treatment is a trivial issue” or even “Noncompliance with treatment is not nearly as big a problem as we thought?”

I didn’t think so.

So, …

To eliminate wasted time and effort of those performing patient compliance research, wasted paper, ink, and server space of printed periodicals and internet sites that host patient compliance articles, and wasted time and effort of those reading those articles, I propose that henceforth authors of such pieces who believe it essential that they introduce the topic of treatment adherence by providing statistical indicators of the extent and impact of noncompliance be mandated to instead enter the following boilerplate with a link to a standardized index of such statistics.¹

You’re welcome.


Footnotes

1. I freely confess that I have contributed heavily to these duplicated efforts. I’m very sorry. [back]

• Meta-Review: Improving Medication Adherence In Chronic Cardiovascular Disorders
• Improving Patient Compliance With Post-Vasectomy Testing
• Status Of Improving Patient Adherence To Cancer Treatment Project
• Improving Patient Adherence in Chronic Heart Failure - Online Continuing Education
• Medication Compliance Research Review

Source: One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic, Andreas Storm, Stig Ejdrup Andersen, Eva Benfeldt, Jørgen Serup Journal of the American Academy of Dermatology. 59:1, 27-33

The Study

Using the Danish National Electronic Pharmacy Register, which contains all prescriptions issued within the past two years, Storm and associates studied 322 people, who were prescribed a total of 390 medications.

At four weeks after the medications were prescribed, 30.7 percent of the subjects had not filled the prescriptions while most people who did obtain the medication did so within the first week after receiving the prescription.

Older patients and those who were treated by specialists were among those more likely to have filled their prescriptions while those with chronic disorders were less likely (when compared to patients treated for acute diseases).

Commentary

There are no surprises; these findings are in line with those of earlier, similar studies.

These confirmatory results do, however, have practical implications for treatment. For example, given how common it is for large numbers of patients to never begin a prescribed medication, clinicians must always give nonadherence a high priority on the differential diagnosis of any treatment failure.

That importance of that reactive step is clear. In addition, I would also suggest a less obvious, proactive step.

One of the few things worse than one-third of all patients not filling their prescriptions is the clinician not knowing that one-third of his or her patients did not get their prescriptions filled. I believe a solid case can be made for working with patients in such a way a to encourage them to disclose that, in this case, they did not obtain the medications prescribed rather than hide it from their healthcare professional. My take on this matter is part of the post in which I originally suggested this tactic:

• CME: Treatment Nonadherence Among Individuals With Schizophrenia: Risk Factors and Strategies for Improvement
• Post-Transplant Medication Errors
• Improving Patient Adherence in Chronic Heart Failure - Online Continuing Education
• Connection Between Knowledge and Compliance Unclear
• Self-efficacy and Social Support Linked To Adherence With HIV Treatment

Are Prescription Labels Readable? Clues From The Marketplace

The preceding post, Check The Fine Print For Noncompliance - Part 1, included a couple of studies indicating that, indeed, there are problems deciphering the medication information and instructions printed on prescription pill bottles in a font size technically known - on this blog - as “too damn small.” That these texts are too often smudged, faded, irregular, and disorganized, as well as plastered onto a curvilinear surface, is just a bonus.

In addition, the marketplace also suggests that the difficulty of reading prescription labels is a recognized and widespread problem.

Otherwise, why would products like the Label Enlarger exist?

Label Enlarger

This Label Enlarger and gadgets like it can be purchased from a number of sources for less than $10.

A more sophisticated device, the pill bottle capable of providing audible label information, was originally developed for blind patients but is now marketed to a wider market, including those with age-impaired vision.

The Talking Pill Bottle

Like the Label Enlarger, the Talking Pill Bottle is available in several versions and from several sources.

Specialized labels, warning symbols, and large print labels are available to patients to transform prescription bottle label information into a format that is clearer and less given to misinterpretation.

Pill Bottle Labels

This, of course, begs the question of why patients have to provide this service for themselves.

What Have We Learned?

The proposition that follows is my own idiosyncratic take on the matter, but it is so basic that I am confident I can defend it easily enough.

1. If special aids are required to read medical instructions on pill bottles, those instructions are too hard to read.
2. Instructions that are too hard to read will not be read as often or as accurately as instructions that are easy to read.
3. Instructions that are not read accurately or not read at all will cause unintentional noncompliance.
4. Noncompliance leads to unnecessary fiscal costs and increased morbidity and mortality.

Other Lessons From The Marketplace

The problem with font size is not limited to prescription medicines.

And the problem doesn’t seem to be going away on its own.

Wanna see something scary? The label formats displayed below are currently offered for sale to pharmacies (I have changed only the pharmacy name; otherwise, these are unchanged from their presentation on the printing companies web site).

Prescription label form sold to pharmacies (click on graphic to view larger image)

Prescription label form sold to pharmacies (click on graphic to view larger image)

Imagine these overfilled, pre-faded labels affixed to the curved surface of a pill bottle. Imagine my Aunt Hazel and Uncle Foster, both in their 90s, trying to read that text.

The Solution and Why It’s Important

Before Ross Perot was a third-rate third-party presidential candidate, he was a creative, successful businessman who would, on occasion, observe, “If you see a snake, just kill it - don’t appoint a committee on snakes.”

Well, in this case, the snake is pretty obvious: The US population is aging with the huge boomers cohort approaching the age when visual changes make reading small print more difficult. Many prescription labels contain medication information and instructions written in especially small type. The inability to read a prescription label or, even worse, the inaccurate interpretation of medical instructions because of impaired vision and tiny print leads to unintentional noncompliance and that, my friend, is a snake.

Having identified this specific snake, killing it turns out to be a straightforward matter - at least, hypothetically. How about this? The government simply passes a regulation forbidding the use of a font size below, say, 12 points, on prescription labels.

Some may protest that providing sufficient information in larger print on a small label is a physical impossibility. Solving that design problem seems, however, less complex than, for example, decreasing automobile pollutants and increasing fuel mileage to meet those progressively more demanding governmental mandates.

Further, some pharmacies have already been at work on this problem. I came upon this example of from HealthPartners.com.

Even the “After” label isn’t perfect but it’s certainly a significant improvement.

Another heartening example I serendipitously discovered comes from Pharmacy In Focus, the Ulster Chemists’ Association’s official trade publication:

While Mr Perot might point out that there seems to have been more snake committee-forming in this process than was essential, especially since the nurses were already aware that “patients had raised previous concerns about their medicines,” a better label system was introduced.

I suspect clever designers could come up with a variety of inexpensive, easy to implement solutions, but even an unsophisticated approach, such as a page attached at one corner to the pill bottle that folded out to reveal the information in readable text, would be better than ignoring the fact that a large and growing number of people can’t reliably read the the essential information about their medication from the labels.

Larger fonts on medication labels is not a panacea for all noncompliance, nor is it a sexy issue likely to attract a high ranking celebrity as spokesperson for the cause.

Instead, it’s a simple problem with simple solutions. Mainly, it requires dropping the pretense that the use of small, unreadable print is a necessary annoyance and changing a few printers to eliminate a lot of grief, decrease the course of treatment for many, and save more than a few lives.

• Check The Fine Print For Noncompliance - Part 1
• The Scrubs Patient Compliance Subplot - Part I
• The Scrubs Patient Compliance Subplot - Part II
• There is a fine line between being a Squeaky Wheel and being a Pain In the Butt
• Noncompliance Basics

Inadequate Font Size As A Cause Of Noncompliance

While young at heart, I am presbyopic of vision. Consequently, I have become aware of the difficulty reading certain types of texts that one routinely encounters on a frequent basis. The day to day category that has proved most troublesome is, by a wide margin, prescription medication labels.

It will surprise no one familiar with my interest in patient compliance that I have been speculating on the likelihood that misunderstanding and frustration engendered by problems reading the instructions jammed onto these labels lead to unintentional noncompliance with medication.

The potential for problems of this sort seems so high, in fact, that I have been surprised how infrequently this issue is listed as a possible cause. Illiteracy and instructions being written in a language other than the patient’s, for example, are much more common in the literature.

This week, I happened onto an exception to this pattern: Barriers to Medication Adherence in Poorly Controlled Diabetes Mellitus by Peggy Soule Odegard, PharmD and Shelly L. Gray, PharmD,¹ identifies challenges to adherence behaviors in 77 patients taking diabetic medication. The pertinent results show that “taking more than two doses of DM medication daily and difficulty reading the DM medication prescription label were significantly associated with higher hemoglobin A1c.”²

The Variability and Quality of Medication Container Labels

Shrank and colleagues published The Variability and Quality of Medication Container Labels³, an assessment of “the format, content, and variability of prescription drug container labels dispensed in the community.”

Excerpted from the abstract:

To illustrate the results of materials printed font sizes, I have provided, in the graphic that follows, lines in Arial typeface in those same font sizes, rounded to the nearest whole number (which is given in parentheses).

Dr. Shrank’s findings are damning, and there is more, but that’s the next post.


Next
Small Print and Noncompliance - Part 2: More Evidence, Solutions, and Why This Issue Is Important (and not just to me)

Footnotes

1. Peggy Soule Odegard, PharmD and Shelly L. Gray, PharmD, Barriers to Medication Adherence in Poorly Controlled Diabetes Mellitus The Diabetes Educator, Vol. 34, No. 4, 692-697. 2008 [back]
2. Increased A1c is used here as a proxy for poor adherence [back]
3. William H. Shrank, MSHS, MD; Jessica Agnew-Blais, et al. The Variability and Quality of Medication Container Labels. Arch Intern Med. 2007;167(16):1760-1765. [back]

• Check The Fine Print For Noncompliance - Part 2
• The Scrubs Patient Compliance Subplot - Part I
• The Scrubs Patient Compliance Subplot - Part II
• There is a fine line between being a Squeaky Wheel and being a Pain In the Butt
• Noncompliance Basics

The Medication Blister Pack Lottery Ticket¹

Aetna-sponsored Clinical Trial Of Lottery As Incentive For Coumadin Therapy Adherence

This story has been kicking around for over a month, evoking a variety of responses from the lay press, healthcare-oriented blogs, bioethicists, and the occasional patient compliance junkie.

Apparently, I can’t resist getting in on the action.

The Clinical Trial

The Aetna Foundation is funding a University of Pennsylvania clinical trial to determine if chances to win a daily low-stakes lottery effectively promotes adherence among coumadin patients.

According to the Hartford Courant,²

Patients who do not report taking their medications are also notified if they would have won the cash but were ineligible because they did not follow their medication regimen.

The Responses

Many reports provided a straightforward account of the trial, but others have played up the cash incentive and the lottery/gambling angles. An example of the those focused on the money, by my subjective evaluation, is Bribe Me, Doc.³ The title notwithstanding, the reporting is reasonably balanced (several articles and, especially, posts attacked the use of cash incentives more aggressively on moral grounds), but the questioning of the compliance enhancement strategy being studied is reflected in these excerpts:⁴

Commentary

A full discussion of compliance-enhancing incentives is beyond the scope of this post and has been addressed in this blog previously. Instead, I’ll offer some comments on pertinent issues that were not been covered in the 20 or so articles about this study I’ve read.

Several healthcare professionals raised similar points to that made by Richard Ashcroft, i.e., the use of cash incentives diminishes the personal responsibility of the patient.

My first and almost automatic response is that adherence to healthcare is not exclusively an individual’s personal issue. Noncompliance increases healthcare costs for all of us, one way or another, and unnecessarily uses the resources to the loss of all those individuals (that would be you and me) who may require healthcare services. Productivity is decreased when health problems of workers are not properly treated. Noncompliance may lead to lack of treatment or inadequate treatment of communicable diseases that consequently puts others at risk for the same disorder in the short term and for even more virulent or more difficult to treat forms of the disorder if inadequate treatment leads to the formation of resistant strains of the disease. If the consensus is that forced treatment or quarantine is necessary in some cases to protect the public, then it is difficult to condemn a less rigorous tactic if that is sufficient for public protection.⁵

On consideration, I’m not fully convinced of the premise that cash incentives necessarily destroy personal responsibility. To make that argument, it seems to me, one would also have to protest against penalties for noncompliance on the same grounds. E.g., fines for traffic violations are unethical because they diminish personal responsibility. Individuals should stop at red lights and adhere to speed limits because of internal motivators rather than external coercion. Of course, my reaction may be skewed by too many years on the parent-child battle line, efforts that long ago caused me to abandon the second half of the proposition “you [my son] must do the right thing and do it for the right reason.” A more pragmatic attitude toward motivation prevails on the home front these days.

I do enthusiastically agree with Richard Ashcroft’s observation that “in the health field that people aren’t always rational in their decision-making.” In fact, if I ever ascend to the role of Universal Emperor Of Healthcare, my first decree shall be to require all healthcare theorists to write that line 1,000 times on the chalkboard. Today, however, I will only add that there are few, if any, fields of personal functioning (e.g., caring for ones health, managing money, finding a career, falling in love, … ) in which decision-making is rational.

I find almost no discussion of the impact the lottery aspect of the incentive might have on the patient-doctor relationship. Is there, for example, any risk that the patient who forgot to take his pill for the first time last night, might, on receiving word that he would have won last night’s jackpot had he been compliant, be miffed at the doctor, who will inevitably be seen as representing the incentive system? Or if there is a snafu,⁶ are the folks whose legitimate winnings dissipate in a computer error going to blame the clinician? Who will be responsible for explaining this to the patient, re-establishing a working relationship, taking the time to fix the errors, etc?⁷

As long as incentives are being passed out to patients, how about providing parallel incentives to the responsible clinicians and any family or friends who take the role of care provider on an everyday basis so that all those involved in treatment are headed toward the same goal? Gee, what’s the word for that? Oh yeah, that would align the stakeholders.

In any case, by using the electronic monitoring device described, the researchers are actually testing if chances to win a daily low-stakes lottery effectively promotes the pressing of a “Yes, I took my medicine” button among coumadin patients. My hunch is that it will.

I will also repeat the recommendation I made in a previous post

Footnotes

1. Consider the Medication Blister Pack Lottery Ticket AlignMap’s contribution to pharmaceutical packaging [back]
2. The Courant story, the primary source of this information for most of the blogged and printed reports, is no longer available via live link. I accessed it through the Google cache at Courant Page 1 and Courant Page 2. [back]
3. Misty Harris , Bribe Me, Doc, Canwest News Service. July 01, 2008 [back]
4. It should be noted that those involved in the Aetna funded University of Pennsylvania study also recognize the ethical issues involved. Their stance holds that if the incentives prove successful in enhancing compliance, the moral and ethical points should be debated after the study is complete. [back]
5. Some of the argument I make in this paragraph may be implicitly included under “public health” references made in some articles. [back]
6. Oh my, I just flashed on the concept of the healthcare system as I know it taking on the management of a lottery system. What could possibly go wrong? [back]
7. For what it’s worth, classic contingency management, a behavioral system with much supportive evidence, would provide each patient with $X in his account on day one and remove a fraction of that every day the patient was noncompliant. Regardless of how effective the scheme might prove in improving compliance, I cannot imagine approaching, say, my borderline patients, at every session to announce that their compliance last week had cost them $29. It would not be a pretty sight. [back]

• Payment For Medication Compliance: Incentive or Bribe?
• Compliance Or Defiance When The Stakes Are Life Or Death
• Promoting Compliance With Pharmacy Benefit Incentives
• Cash For Compliance & Other Ethical Dilemmas
• Another Case Of Cash For Compliance

Calvin: Let’s say that life is this square of the sidewalk. We are born at this crack and we die at that crack. Now we find ourselves somewhere inside the square and in the process of walking outside of it. Suddenly, we realize our time in here is fleeting. Is our quick experience here pointless? Does anything we say or do in here really matter? Have we done anything important? Have we been happy? Have we made the most of these precious few footsteps?

From Calvin To Compliance

Calvin’s use of the sidewalk as a metaphor to explore the meaning of life triggers Donald B Ardell, in Calvin, Deep Questions And Promoting Exercise, to apply the same questions to the value of health education:

Happily, there is some reason for cautious optimism. The post continues,

Commentary

I chose to post on this issue because (1) I’ve long been a big fan of Calvin & Hobbes so I jumped on the first semi-legit rationale to feature them on this blog, and (2) Donald Ardell makes an important point that isn’t often emphasized on this site.

Although I am a dedicated proponent of a tailored approach to improving compliance (i.e., selecting the most efficacious compliance-enhancing interventions for a given patient or patient group) and, indeed, promote that stance in a commercial venture,¹ there is substantial evidence, including the study Mr. Ardell references, that brief, non-specific counseling from a healthcare or wellness provider to exercise, to follow a healthy diet, to quit smoking, … can be effective for at least a portion of the population.² Given the small amount of time and the relative ease of offering such advice, there is little excuse not to do so and, as Calvin and Mr. Ardell would point out, profound gratification in providing this service to our clients.

For the record, Calvin and Hobbes do offer another approach to motivating others.

Footnotes

1. See EnrichMap and Emap Profile Now Online and the EnrichMap web site. [back]
2. See, for example, How Physicians Can Help Their Patients Quit Smoking by Prochazka and Boyko, West J Med. 1988 August; 149(2): 188–194 [back]

• Diabetics Weigh Cost Of Compliance Vs Longer Life
• Life Insurance For HIV Patients Contingent On Treatment Compliance
• Compliance Or Defiance When The Stakes Are Life Or Death
• LIFE Program Enhances Adherence
• Noncompliance Despite Life Or Death Stakes

A Cognitive Therapy Approach to Weight Loss and Maintenance: An Expert Interview With Judith S. Beck, PhD Judith S. Beck, PhD, Medscape Psychiatry & Mental Health. Posted 04/23/2007

Do Cognitive Therapy Concepts For Losing Weight Apply To Improving Compliance?

I’m convinced this Medscape interview with Judy Beck on a cognitive therapy approach to weight loss has straightforward implications for optimizing patient compliance. Rather than argue the case, however, I encourage you to check it out for yourselves. To facilitate this process, I’ve excerpted some of the portions of the interview that are pertinent to treatment adherence. I suggest reading through the selections once for a sense of Dr. Beck’s notions regarding cognitive therapy and weight reduction and then re-reading the same material, mentally transforming the goal from weight loss to patient compliance. I think you’ll find the exercise simple and enlightening.

Medscape: Do people become demoralized when they find out that dieting isn’t as easy as they had thought?
Dr. Beck: Yes. That’s why it’s important to lay the groundwork with dieters first. In fact, I suggest that people spend a couple weeks learning certain skills before they even start. One skill is to compose and read every day a list of every advantage they can think of for losing weight. They’ll need to read this list for a very long time, so when they face temptation, these advantages will be firmly in mind. And they need to prepare in advance what to say to themselves when dieting gets harder, when they feel discouraged, when the scale hasn’t gone down, when they stray from their diet, and when they start to feel the injustice of food restriction.

Medscape: What role does distorted thinking play in unsuccessful efforts to lose weight?
Dr. Beck: Dieters who fail to lose weight or fail to maintain their weight loss think differently from those who are able to lose weight and keep it off long term. They have a lot of all-or-nothing thinking:

* Being full (often overly full) is good; hunger is bad;

* They’re good if they follow their diets, but bad if they make 1 mistake;

* Their eating week was either good (relatively easy) or bad (even if they only struggled for several minutes on several days);

* Food is either good or bad even though we recommend that dieters plan in advance to modify their diets so they can eat small portions of whatever food they want as often as once a day; and

* Dieters who fail to lose weight also view themselves as either in control (100% perfect) or out of control. They often think that 1 mistake should give them license to eat whatever they want for the rest of the day and delay starting fresh until the next day. They also believe that people of ‘normal’ weight rarely restrict their eating and rarely get hungry. They think that once they lose weight, they should be able to return to their old way of eating.

Medscape: How do you get people to recognize these kinds of ideas and what do you suggest they do about them?
Dr. Beck: We use standard cognitive therapy techniques, teaching them to ask themselves what’s going through their minds when they feel hunger and craving, when they are disgruntled about not eating, when they are tempted to eat something they haven’t planned. Then they read ‘response cards’; index cards that contain compelling answers to their thoughts. They read these cards at least once a day, usually in the morning; then pull them out again on an as-needed basis, sometimes several times a day toward the beginning of their diet.

Medscape: Can you give an example of a response card?
Dr. Beck: We make them up idiosyncratically with dieters. Some common ideas are: Even though I really want to eat now, I haven’t planned to. If I eat, I’ll strengthen my ‘giving-in’ habit, which means in the future I’m more likely to give in. If I don’t eat, I’ll strengthen my ‘resistance’ habit, which makes it more likely that in the future I’ll be able to resist. I can tolerate not eating now. I’ll be very glad in a few minutes when the desire goes away. I shouldn’t give myself a choice about this. After all, I’d rather be thinner. I can’t eat whatever I want AND also be thinner. I have to make a choice. Every time matters.

Medscape: What about emotional eating?
Dr. Beck: Dieters give themselves permission to stray from their diet for any number of reasons. They’re upset, happy, tired, stressed, celebrating, traveling, busy, at a party…the list is endless. They think, ‘It’s okay to eat because…. everyone else is; it’s only a small piece; no one is watching; the food is free; I rarely get a chance to eat this kind of food.’ They need to learn the same skills to avoid straying from their plan, no matter what the reason. They have to grasp the fact that they can either eat what they want, when they want, for whatever reason they want (including being upset) — or they can be thinner. But it’s impossible to have it both ways.

Medscape: What do you suggest people do when they’re tempted by food that they’re not supposed to eat?
Dr. Beck: As I keep saying, they have to prepare in advance for these times. They need to continually remind themselves (often by reading response cards) of the reasons to lose weight, that they can tolerate the discomfort of not eating (after all, they’ve tolerated much worse discomfort in their lives), that they’ll be happy in a few minutes when the desire to eat passes that they didn’t eat and they’ll be very unhappy in a few minutes if they give in to temptation. They also need a list of things they can do when they feel tempted — such as reading a diet book, surfing the Web for diet-related sites, taking a walk, calling a friend, brushing their teeth, writing emails, and so forth. We help dieters create a list of about 20 activities or so and urge them to try 5 of them each time they’re tempted.

Medscape: You mentioned that dieters need someone to be accountable to.
Dr. Beck: Yes, we encourage everyone to find a ‘diet coach’: a friend, family member, coworker, neighbor, or maybe someone else who is trying to lose weight. Diet coaches don’t necessarily need to know much about dieting. But they do need to be highly supportive and encouraging. They also need to be willing to hunt down the dieter who has failed to keep his or her regularly scheduled weekly appointment (by telephone or email, or in person), reporting on how his/her weight has changed that week. Dieters don’t need to reveal their weight; only their change in weight. In addition, diet coaches need to be good problem solvers.

Medscape: What kinds of problems arise that dieters need help with?
Dr. Beck: Common problems include practical ones, such as not enough time to schedule in dieting and exercise activities, and psychological ones, such as demoralization and discouragement. Some dieters need encouragement (and sometimes a little assertiveness coaching) to state their needs to family and coworkers. It’s surprising how many dieters are reluctant to turn down food that others offer or to ask that others bring only a single serving of overly tempting foods into the home, at least at the beginning. Ultimately, we want to build up dieters’ control so that they can keep any kind of food in the house and eat only small, planned-in-advance amounts.

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