Excerpted from Stroke Connection Magazine, July/August 2004.
At first glance, compliance appears to be a patient problem: If patients would just do what they’re told, everything would be fine. The reality is much more complex, and when we began investigating why noncompliance is so widespread, we found that there are many barriers. In Part I (May/June 2004) of our two-part series, we looked at the psychological barriers to compliance. In Part II, we will investigate some of the challenges that external circumstances may contribute as survivors try to follow doctors’ orders.
1. Not enough time with the doctor.
In our reimbursement-driven healthcare system, physicians’ time is at a fi nancial premium. Unfortunately this works against patient education, and patients who don’t understand their treatment or its rationale have a hard time following directions.
“Patients really want to talk to doctors,” says Dr. Thomas Swift, president-elect of the American Academy of Neurology and professor emeritus at the Georgia Medical College in Augusta. “When patients share their symptoms, they feel better, but doctors don’t get paid for that anymore, and the patient suffers.”
2. Too many medications and too many complicated lifestyle prescriptions for diet, exercise and stress reduction.
Many stroke survivors have to take multiple medications. This may be particularly true if an underlying condition such as heart disease, high blood pressure or diabetes contributed to the stroke. The more complicated the drug or lifestyle prescription, the less likely a patient will follow it.
3. Too many doctors.
With the proliferation of specialties, patients may have several doctors and get sometimes conflicting advice and requirements. Few families have a central health monitor who directs medical traffic and ensures that patients successfully navigate the maze of therapeutic requirements. Faced with complicated treatment plans that don’t automatically mesh, patients often make uninformed choices, or simply give up in frustration.
Drugs are expensive, and even patients with good insurance may find that their policy is deficient in prescription coverage. Recently TIME reported that drug costs represent almost a quarter of out-of-pocket medical expenditures. Patients on fi xed incomes may have to choose between their prescriptions and other necessities.
Patients sometimes use the excuse of feeling better or worse to stop taking a drug that strains the budget. In an effort to stretch their medicine, they may reduce the amount they take or the frequency, hoping it will still be effective. But any drug not taken as directed can’t work as expected. When patients don’t follow their treatment plan, they can’t get maximum benefit from it.
1. Not enough time with the doctor.
“The most important thing is the doctor-patient relationship,” says Dr. Swift, “and that can’t be built in 10 minutes. Friendships are key to healing. Patients’ biggest complaint is that their doctor doesn’t talk to
them. What they are really saying is, ‘My doctor won’t be my friend.’” Short of a revolution in healthcare reimbursement, there is little any patient can do about that, but here are some things that may help:
Go to your appointment with written questions. Find out as much as you can about your condition and write down questions to ask your doctor. Keep a pad where you store your medicine so you will have a central place for writing down questions.
Request that a loved one be present during your appointment to take notes. Ask if you can record the doctor’s orders so you can review them. “This is a sensitive area,” says Dr. Swift. “Some doctors feel threatened. I personally don’t mind. At the very least, the patient should write down the plan and repeat it to the doctor.”
2. Too many medications.
In The Essential Guide to Prescription Drugs 2004, Dr. James Rybacki suggests several ways of simplifying medication problems.
Create a medication map. A medication map is a schedule covering the whole day. It plots when you take what medicine, the dose and any other instructions, such as nutritional support. It organizes all your medication in one place so you see at a glance what, when and how much. A dosing calendar is also helpful because you can check off the date after taking your medicine.
Schedule a “brown bag” session with your doctor or pharmacist. Put all your prescription and non-prescription medications in a bag and take them to your doctor’s office or pharmacy. They may find overlapping or duplicate prescriptions from different doctors. This would also be a good time to make a medication map. Periodic medication reviews allow you to ask if simpler alternatives are available.
3. Too many doctors.
Appoint a healthcare gatekeeper. Find a doctor you trust and ask him or her to serve as the ultimate arbiter of your treatment. This way you won’t have to make uninformed decisions about confl icting advice or therapies. Ask your pharmacist to review all your medications for problem interactions and then ask your primary care physician to resolve the problem.
“A fundamental problem is that there are different treatments from different doctors,” says Dr. Swift. “You can’t get away from that.
Different doctors come to different conclusions on the same facts. There will always be alternative ways to treat things. No one treatment is the only way of treating something so you must trust your physician.”
Comparison shop. Investigate the prices charged for your prescriptions at several pharmacies. Also check prices at online pharmacies, but remember — it’s hard to verify the credibility of Internet vendors.
Investigate Patient Assistance Programs. Most drug companies have special programs that discount certain drugs. They are called Patient Assistance Programs (PAP). Who qualifies, what is required to participate and the discount varies for each company. Individual company Web sites can give you the specifi cs. Just type in the company name in Google, and that will link you directly to the company’s home page. For more general information on PAPs, visit www.rxassist.org or www.needymeds.com.
Ask your doctor about lower-price alternatives. Before you leave your doctor’s office, ask that they check to see if your prescription is covered by your insurance plan. If it isn’t, they may be able to switch you
to a drug that is. Tell the truth to your doctor about your ability to pay for medication.
5. Physical limitations.
The Internet essentially brings the pharmacy to your door. Online ordering could be the answer for anyone with limited mobility because you get your medications delivered to your door. Most brick-and-mortar pharmacies have Internet ordering sites, so you don’t have to start with a new company. If you cannot get on the Internet, ask a trusted friend or relative to place the order for you or find out if your physician can do it for you.
Another alternative includes finding a local pharmacy that takes phone-in orders and delivers. And there are mailorder pharmacies such as the one operated by AARP.
Stroke survivors are often patients for the rest of their lives, but about half of them fail to follow doctor’s orders. Not only is that a huge waste of money — why pay for advice you’re not going to follow — but
it’s also a wasted opportunity for stroke families to improve their quality of life.
Read Part I on this topic to learn about the psychological challenges stroke survivors face in following doctors' orders.