I want to start this article by telling a story of one of my patients; we’ll call him Mr. Jones. Mr. Jones was a 45-year-old contact lens over-wearer. He presented complaining of progressively worsening foreign body sensation and redness. Examination showed large papillae in the upper tarsal conjunctiva bilaterally. Given his symptoms and clinical signs, I diagnosed him with giant papillary conjunctivitis. Next, I let Mr. Jones know to temporarily discontinue contact lens wear, start taking a soft steroid drop four times a day and to see me back in a week. A week later, Mr. Jones returned with no improvement, increased frustration and, therefore, a decreased trust in me.
Rattled, I started going down the list of what I may have missed. I then stopped myself and asked Mr. Jones, “How did you take the drops?” Mr. Jones replied, “I put four drops in the morning; it didn’t help, so I stopped using it.”
I realized that the lack of confidence Mr. Jones had in me wasn’t due to misdiagnosis or incompetence, it was due to ineffective communication of medication instruction. After my interaction with Mr. Jones, I have made it a habit to remember six categories that I always want to specify when explaining a treatment to effectively communicate with my patient.
1 DIAGNOSIS IN NEED OF TREATMENT
Optometrists should explain their thought process of why they are prescribing a certain medication. This can include the factors that led to the diagnosis and the mechanism of action in a therapy. “Mr. Jones, I am prescribing you a steroid because this is an inflammatory response caused by an allergic reaction — most likely from contact lens overuse. The steroid will work to reduce the inflammation.”
2 AMOUNT OF DRUG TO TAKE
This may seem obvious to us, yet patients often don’t know that one drop is adequate. If the patient is using several drops, in most cases, it is wasteful, and the patient may run out of the medication prior to the intended duration. This can result in reduced effectiveness, so O.D.s should educate patients, where pertinent, that one drop is adequate. “Mr. Jones, I would like you to use only one drop in each eye. Our eye can only hold so much liquid, and any excess can be wasteful, as it will run down the side of your cheek, not produce a greater effect.”
3 WHEN TO TAKE THE MEDICATION
Optometrists should explain to their patients when to take the medication. For instance, if an O.D. tells a patient to instill a drop four times a day, the patient may take this to mean to take all four drops of the medication at the same time in the morning, which will, of course, limit the effectiveness of the prescribed treatment. “Mr. Jones, I want you to instill this medication four times a day, roughly four hours apart from one another. A good schedule to follow is using one drop in the morning when you wake up, one drop at lunch time, one drop at dinner and another right before you go to bed.”
4 ROUTE OF ADMINISTRATION
Although the route of treatment in our setting is typically ophthalmically, patients can still experience confusion. I have, particularly, encountered this with ointments: There can be hesitation in a patient’s mind of whether to place the medication on the eyelid or within the eye itself. As a result, it’s worthwhile for us to specify the route of administration, even if it seems like it should be uncomplicated. “Mr. Jones, this is an ophthalmic drop that is supposed to act directly on the inflamed tissue. For that reason, we want to put it inside the eye, as that is where the inflammation is present.”
5 ADMINISTRATION ITSELF
Even if a patient understands the use directions completely, if she is unable to properly instill the eye drops as prescribed, that is, debatably, more ineffective than not understanding the correct directions. As a result, I always give my patients some tips to help, and I even have them demonstrate to me their ability to instill drops, so I can ensure they will adequately get the medication they need. One tip I love sharing with patients is to refrigerate their drops, so it’s easier to tell that the drop has gone in their eye. Also, I educate any family members who may be helping with the patient’s care. “Mr. Jones, this medication is meant to be dropped in your eye; a good tactic to administer it is to pull down your lower lid, tilt your head back, and look at the dropper as you squeeze the bottle. You will feel the drop go in the eye.”
6 WHEN TO DISCONTINUE
Optometrists should tell a patient exactly when to discontinue a medication, so she won’t discontinue it too early or overuse the medication. An example of how to provide this needed information: “Mr. Jones, I want you to use this medication for the full week. It’s important that you adhere to this schedule, because there are side effects to both ending the therapy too early and too late. Discontinuing use too early can lead to an incomplete resolution of the issue. In contrast, overusing the medication can lead to excessive side effects and, in some instances, bacterial resistance, medication dependency or increased tolerance.”
LET’S DO WHAT WE CAN
It is important to understand that poor communication is not the only reason for non-compliance. (See “Is it something I said?” below.) There are several additional reasons medication non-adherence is common. For example, I have had patients tell me they understood how to take their medications, but they intentionally reduced the dose to make them last longer, to save money and/or to reduce side effects they may be experience. This seems to be particularly true when the condition is asymptomatic.
Although there are many reasons our patients may not comply with their medications, we can rectify the communication reason by remembering the six items above. Making this simple effort, we are able to build trust with our patients, increase rapport and garner word-of-mouth referrals, which grow our practices. OM
Is It Something I Said?
NEARLY 20% OF MEDICATIONS that a doctor believed to be a viable solution were not taken correctly by a patient, according to a study published in the Annals of Family Medicine. About 50% of the time, the patient either forgot, ran out of the medication or was careless about when he took the medication. These behaviors were defined as unintentional non-adherence to prescriptions. In the opposing 50% of the time, the patient deliberately chose not to take the medication correctly.
This study emphasizes a correlation with adherence and good communication between the doctor and the patient. Worth noting, the study also points out that, generally, there is an inverse correlation between physician responsibilities and their communication skills. It is important that we take that into consideration, and as our practices get busier, as we grow as doctors, we take the time to effectively communicate with our patients.
Further, the study suggests that integrating other health professionals, such as pharmacists, may help bridge the communication gap by checking the patient’s understanding of medication use at different touchpoints. This may help fill in the knowledge gaps and, ultimately, help maximize the effectiveness of medication.
→ Read the study in its entirety at www.annfammed.org/content/14/5/415.full .