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Concordance, not compliance. Read the
original!
3-1 WRITING PRESCRIPTIONS IS EASY
A working party of the Royal Pharmaceutical Society of
Great Britain has published a report on medicine taking.
It was set up to consider the scale and consequences of
non-compliance and to make recommendations.
The intention is to form a therapeutic alliance—to
help the patient make as informed a choice as possible
about the diagnosis and treatment. Although this alliance
is reciprocal, the most important determinations are made
by the patient. This they term "concordance".
Compliance may have been appropriate in the time when
services were driven by benign paternalism. Now, values
are changing. The price of compliance is dependency. It
belongs to another world. The price of concordance will
be a greater responsibility—in the doctor’s
case for the quality of the evidence, diagnosis,
treatment, and explanation; in the patient’s case,
for the consequences of his or her choices. BMJ March 8,
1997; 314: 747-48 3-1
WRITING PRESCRIPTIONS IS EASY
"Only about 50% of patients take their medicines in
therapeutically effective doses. The cost of
non-compliance in illness and premature death is
staggering... ."
A working party of the Royal Pharmaceutical Society of
Great Britain has published a report on medicine taking.
It was set up to consider the scale and consequences of
non-compliance and to make recommendations. At the outset
many patients admitted that they rarely took medicines as
prescribed. Some confessed to abandoning courses of
antibiotics after the first day or two.
Efforts to improve compliance have met with little
success. There seems to be two reasons:
1) Resistance to taking medicine seems to be quite
profound and pervades different cultures. It is
instinctual and complex; 2) There is something morally
and psychologically flawed in the very concept of
compliance.
Compliance may be described as follows: The patient
presents with a medical problem for which there is a
potentially helpful treatment. What the doctor brings to
the consultation—scientific evidence and technical
skill—is classified as the solution. What the
patient brings—health beliefs based on experience,
culture, personality, family traditions, and so
on—is seen by the doctor as the impediment to the
solution. The doctor’s task is to overcome the
impediment.
The group suggests a different and more robust model of
the relationships between doctors and patients. The
clinical encounter is concerned with two sets of
contrasting but equally cogent health beliefs—those
of the patient and those of the doctor. The
patient’s task is the tell the doctor his or her
health beliefs and the doctor’s task is to enable
this to happen. The doctor must also convey his or her
(professionally informed) health beliefs to the patient.
The intention is to form a therapeutic alliance—to
help the patient make as informed a choice as possible
about the diagnosis and treatment. Although this alliance
is reciprocal, the most important determinations are made
by the patient.
"We call this model concordance. It recognizes that,
just as all prescribing is an experiment carried out by
the doctor, so all medicine taking is an experiment
carried out by the patient. Concordance does not imply
any abandonment of the evidence from science on part of
the doctor."
Compliance may have been appropriate in the time when
services were driven by benign paternalism. Now, values
are changing. The price of compliance is dependency. It
belongs to another world. The price of concordance will
be a greater responsibility—in the doctor’s
case for the quality of the evidence, diagnosis,
treatment, and explanation; in the patient’s case,
for the consequences of his or her choices. Concordance
will also require the scarcest of commodities—more
time in the consultation.
BMJ March 8, 1997; 314: 747-48 Essay from the
United Medical and Dental Schools of Guy’s and St.
Thomas’s Hospitals, London
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