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Obeying doc’s orders

  Thursday, 26 l 08 l 2010 Source:  Mind Your Body; The Straits Times   
By: Dr Goh Su Yen

Madam T’s children looked at me suspiciously as I waved the syringe and needle at her.

“Mother said she’d rather die than start on insulin, you know?” they chorused.

Madam T, who has had diabetes for more than 10 years, was already on four types of diabetes pills from her regular physician. Her test results were not good. The last two doctors she had seen had correctly prescribed insulin therapy.

The insulin, however, lay unused in her fridge. Her family discovered the untouched stash and her pristine abdominal skin (the usual site for insulin injections) and confirmed what they already knew – she was not giving herself jabs.

Was it needle-phobia? The misconception that insulin would expedite a decline in health? Fear of having low sugar levels?

I asked Madam T for permission to give her a demonstration injection on the spot. She flinched and looked away. She did not even feel the tiny needle going in and out.

“Huh? It’s over? Wasn’t as bad as I had imagined,” she muttered.

There was a collective sigh of relief in the consultation room.

We gave her a convenient disposable insulin pen and one of our nurse educators taught her how to measure her blood sugars at home. Phone numbers and e-mail addresses were exchanged.

This problem has been given many names – compliance, adherence, cooperation, concordance. To the patient, it probably sounds more like coercion.

Contrary to what some may think, this is not just the problem of the foolish, the poor or the uneducated.

Do we really know the magnitude of the problem? An oft-quoted number bandied around is that a third to half of the patients in the United States do not take their medication as instructed.

How many of you would readily admit to it? Some of us no longer ask our patients: “Are you taking your medication?”

It has now become: “How many times per week do you tend to miss your dose?”
Most confessions in my clinic usually come at the point when I am escalating the dose or adding another drug to the prescription.

“Erm... doc, actually I took that pill only once instead of three times a day and hardly on weekends. So that is probably why my test results are bad. Don’t increase the dose, ok?”

Perhaps it is akin to cheating on parking coupons – you think you are saving a bit and there is almost a thrill knowing you have managed to cheat the system. However, the penalties for not adhering to a treatment hurt more than a $50 fine.
We have known for quite a while that not heeding medical advice – ranging from a doctor’s call to make lifestyle and dietary changes to sticking to a medication regimen – can affect one’s quality of life and lifespan adversely.

We also know that adhering to doctors’ advice can improve health outcomes and reduce the number of hospitalisations and health-care spending. So what is preventing people from listening to their doctors?

The list of potential roadblocks is long – a lack of care coordination, the prohibitive cost of medication, poor health and general literacy, language barriers, side effects of medication, polypharmacy (when a patient has
many forms of medication to take), socio-psychological barriers and plain old

In Madam T’s case, the nurse educators called her twice weekly for the first few weeks when she started insulin therapy to check on her. They organised her pill box and drew a pill chart in Mandarin for her. It took many hours from a committed team and that was just for one patient.

Her grandchild hooked up her glucometer to a home docking station to transmit her blood sugar results to the nurses electronically.

Harnessing technology is not new in the field of adherence. iPhone apps and programs for secure text messaging for medication reminders are already on the market.

Our challenge is to identify what motivates the patient to follow treatment instructions.

One of our most compliant patient groups is pregnant mothers with diabetes. This is so whether they had pre-existing diabetes or whether they developed glucose intolerance during pregnancy, and whether they are on strict diets and a carbohydrate counting programme or require insulin injections four
times a day.

What motivates this group of patients is obvious. What we have not figured out is how other patients decide to follow or not follow what has been prescribed for them.

I would go so far as to call this a “public health crisis”. As the late US Surgeon General C. Everett Koop said: “Drugs don’t work in patients that don’t take them.”

Dr Goh Su-Yen is the director of the diabetes clinical services and a consultant at the department of endocrinology at the Singapore General Hospital.

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