Study: Doctors often lecture noncompliant patients too much

For patients with HIV, strictly adhering to their regimen of antiretroviral drugs is not just critical but life-sustaining. So when patients admit to drug noncompliance, doctors are faced with how to help them take their drugs as prescribed.

But rather than engaging in open-ended conversations to address barriers to adherence such as side effects, patient misunderstanding and scheduling, physicians tend to ask yes-or-no questions and tell patients what to do, said a study published online Jan. 31 in the journal AIDS and Behavior.

As important as medication compliance is to HIV care, only 10% of discussion time with patients is devoted to antiretroviral treatment, said the study, based on audio recordings of patient visits to physicians and other health professionals. Researchers categorized the discussions based on whether they were expressive, emotional, empathic, directive, problem-solving, joking and so on.

Nearly half the patients prescribed antiretroviral medications told researchers they were less than 100% drug-compliant. About 90% of the time, these patients did hear from their physicians about the importance of drug adherence, but doctors focused on problem-solving just 23% of the time. When discussing medication compliance, the physicians and other health professionals studied typically asked four closed or leading questions and rarely asked open-ended questions or checked if patients understood what they were being told.

"Even when there is problem-solving talk, there is very little of it," said Ira B. Wilson, MD, senior author of the study. "What's going on instead of problem-solving is what we call directives. It's natural in the course of the physician-patient dialogue around medication adherence for physicians to encourage, to exhort, to cheerlead patients. ... If you're going to help people problem-solve, you need to have a discussion about those problems."

Patients with HIV are likelier than other patients to have struggles with employment, housing and substance abuse, the study said.

Not just an HIV care problem

Generally, between 30% and 60% of all patients fail to take their medicines as prescribed, according to previous research cited in the study. The rate at which physicians take a patient-centered approach to improving drug compliance is probably lower among physicians treating patients with illnesses other than HIV, said Dr. Wilson, chair of the Dept. of Health Services, Policy & Practice at the Warren Alpert Medical School of Brown University in Providence, R.I.

"Everybody knows the game in HIV care is very much about medication adherence. If patients take their meds, they can turn this fatal disease into a chronic illness. Look at Magic Johnson," Dr. Wilson said. "Awareness of, consciousness of, discussion of medication adherence in most other conditions is probably much less. I think this is as good as it gets."

Physicians ought to receive more training on how to employ motivational interviewing and other techniques that can help spur higher adherence rates, Dr. Wilson said. Simply asking patients how they feel about their medications can solicit a lot of information about their drug-taking habits.

"This research is not a criticism of physicians," he added. "This is an observation about the culture that's grown up around complicated behaviors such as medication nonadherence, and our difficulties in cracking that nut and solving that problem. ... We need to get over the idea that we just give the patient information and then it's up to them to take action."