The Worst Patients in the World

David Freedman
The Atlantic - July 2019 Issue

Here are two excerpts:

Recriminations tend to focus on how Americans pay for health care, and on our hospitals and physicians. Surely if we could just import Singapore’s or Switzerland’s health-care system to our nation, the logic goes, we’d get those countries’ lower costs and better results. Surely, some might add, a program like Medicare for All would help by discouraging high-cost, ineffective treatments.

But lost in these discussions is, well, us. We ought to consider the possibility that if we exported Americans to those other countries, their systems might end up with our costs and outcomes. That although Americans (rightly, in my opinion) love the idea of Medicare for All, they would rebel at its reality. In other words, we need to ask: Could the problem with the American health-care system lie not only with the American system but with American patients?

(cut)

American patients’ flagrant disregard for routine care is another problem. Take the failure to stick to prescribed drugs, one more bad behavior in which American patients lead the world. The estimated per capita cost of drug noncompliance is up to three times as high in the U.S. as in the European Union. And when Americans go to the doctor, they are more likely than people in other countries to head to expensive specialists. A British Medical Journal study found that U.S. patients end up with specialty referrals at more than twice the rate of U.K. patients. They also end up in the ER more often, at enormous cost. According to another study, this one of chronic migraine sufferers, 42 percent of U.S. respondents had visited an emergency department for their headaches, versus 14 percent of U.K. respondents.

Finally, the U.S. stands out as a place where death, even for the very aged, tends to be fought tooth and nail, and not cheaply. “In the U.K., Canada, and many other countries, death is seen as inevitable,” Somava Saha said. “In the U.S., death is seen as optional. When [people] become sick near the end of their lives, they have faith in what a heroic health-care system will accomplish for them.”

The info is here.

Don’t Nudge Me: The Limits of Behavioral Economics in Medicine

Aaron E. Carroll
The New York Times - The Upshot
Originally posted November 6, 2017

Here is an excerpt:

But those excited about the potential of behavioral economics should keep in mind the results of a recent study. It pulled out all the stops in trying to get patients who had a heart attack to be more compliant in taking their medication. (Patients’ adherence at such a time is surprisingly low, even though it makes a big difference in outcomes, so this is a major problem.)

Researchers randomly assigned more than 1,500 people to one of two groups. All had recently had heart attacks. One group received the usual care. The other received special electronic pill bottles that monitored patients’ use of medication. Those patients who took their drugs were entered into a lottery in which they had a 20 percent chance to receive $5 and a 1 percent chance to win $50 every day for a year.

That’s not all. The lottery group members could also sign up to have a friend or family member automatically be notified if they didn’t take their pills so that they could receive social support. They were given access to special social work resources. There was even a staff engagement adviser whose specific duty was providing close monitoring and feedback, and who would remind patients about the importance of adherence.

This was a kitchen-sink approach. It involved direct financial incentives, social support nudges, health care system resources and significant clinical management. It failed.

The article is here.

Patients who refuse their physicians’ advice

By Alex Lickerman
www.kevinmd.com Blog
Originally published December 17, 2013

Here is an excerpt:

While no medical intervention is 100% safe, the flu shot (for those not allergic to eggs) is pretty close. Yet every season, I never fail to have some of my patients refuse it. The most common reason I hear is, “I’ve never had the flu.” To this, I invariably say something like, “Just because you haven’t had a heart attack yet doesn’t mean you shouldn’t exercise.” I’d say roughly about half of my patients change their minds and decide to get the flu shot after I talk with them about it.

Over the years I’ve had numerous patients refuse my advice. It always bothers me — not because I like to think I’m right and my ego gets bruised, but because I genuinely believe my advice is in the best interest of my patients and I want them to do well. But over the years I’ve come to see that there are really two basic reasons patients refuse my advice, and that my response to them should be different.

The entire blog post is here.

Under-Treatment, Treated.

By Iain Brassington
BMJ Group Blogs
Originally published August 29, 2013

Right: file this paper from the JAMA under “Properly Odd”: it’s a proposal that nonadherence to a treatment regime be classed as a treatable medical condition in its own right.

No, really.  Look at the title: “Medication Nonadherence: A Diagnosable and Treatable Medical Condition”.

Starting from the fairly straightforward premise that non-adherence to treatment regimes is “a common and costly problem”, Marcum et al move at the end of their opening paragraph to have medication nonadherence recognised “as a diagnosable and treatable medical condition”.

The entire blog post is here.

When the Patient Is ‘Noncompliant’

By DANIELLE OFRI, M.D.
The New York Times
Originally published November 15, 2012

Here are some excerpts:

“Noncompliant” is doctor-shorthand for patients who don’t take their medications or follow medical recommendations. It’s one of those quasi-English-quasi-medical terms, loaded with implications and stereotypes.

As soon as a patient is described as noncompliant, it’s as though a black mark is branded on the chart. “This one’s trouble,” flashes into most doctors’ minds, even ones who don’t want to think that way about their patients. And like the child in school who is tagged early on as a troublemaker, the label can stick around forever.

(cut)

“Improving adherence is a team sport,” Dr. Steiner adds. Input from nurses, care managers, social workers and pharmacists is critical.

The entire article is here.