Why Technology May Not Fix The Medication Adherence Problem

Shaywitz of Eldred

I wish I could assign Lisa Rosenbaum’s characteristically wonderful essay in the latest New England Journal of Medicine to every twentysomething programmer in Silicon Valley planning to disrupt healthcare based on his uninformed interpretation of the problem to be solved.

Consider – as Rosenbaum does – the problem of medication adherence.  As many as half the Americans prescribed medications don’t take them as recommended, even after a heart attack – despite very strong evidence of benefit in this context (namely, the prevention of a second heart attack).

At first blush, this seems like a perfect opportunity for a smart app, or a clever pill case that monitors usage and reminds forgetful patients to take their next dose.  In fairness, for many patients, such technological innovation might prove impactful. Yet what Rosenbaum (a cardiologist) captures in her piece are the many reasons why patients, in the real world, deliberately choose not to take their medicines – even after a heart attack.

Some patients begin with an intrinsically negative view of medicines, and consequently tend to exaggerate potential side effects, and underestimate the likely benefits.  Other patients choose not to take medicines because they don’t like to be reminded that they are sick – each pill taken to stay healthy paradoxically reinforces the concept that they are ill. Of course, many patients avoid medications because of the view that drugs are chemicals and therefore “unnatural” — in contrast to vitamins, or herbal remedies, which presumably are made only of organic goodness.

Still other patients subscribe to the view that “if it ain’t broke- don’t fix it,” and prefer to avoid medications when (as in the case of preventive care) the benefit is often imperceptible.  (There seems to be less discussion of non-adherence in the context of oxycontin, for example.)

Finally, many patients experience medications as a loss of control; the requirement to regularly take a medicine conveys an unwelcome sense of dependency. These explanations are immediately familiar to anyone who’s paid attention to how people discuss medications in the real world (or who has seen how many airline passengers seem to be reading Natural Cures “They” Don’t Want You To Know About), yet may be underappreciated by both the harried physician prescribing the drugs and the earnest technologist hoping to remind patients to take them.

It’s possible, of course that technology could help patients in each of these categories; I remember Aza Raskin suggesting something like a drug-sensitive skin tattoo that would dissolve progressively over a ten-day course of antibiotics, for instance, thus addressing the “imperceptible benefit” problem.  However, if you are developing a product based solely on the assumption that patients don’t take medicines because they are forgetful, then in the words of the inimitable Dave McClure, your solution is not my problem.

I might even go a step further, and suggest that while some clinicians may dismiss technology solutions based on ignorance, fear, or an aversion to change, in other cases, experienced clinicians recognize the messy complexity of real-world medicine, and understand the patient/doctor relationship is seldom captured by the discrete “diagnosis -> treatment” paradigm that many technologists seem to assume. I’d wager that improved adherence — and a range of other health benefits — are ultimately more likely to be achieved not by clever apps and wireless gadgets, but rather by an empathetic physician who understands, listens, and is trusted by her patients — assuming, of course, she can develop these relationships within the constraints of episodic fifteen minute encounters.

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  1. If you look at these diagrams in Nature or Science of the proteome, you will say to yourself “We will never understand what is really going on”….it is so amazingly complicated. Taking any drug is like forcing a needle into this complicated watch and hoping you only hit the proper gears. Everyone taking a drug is doing this: hoping. And because there are thousands of metabolic diseases and disorders almost everyone has some idiosyncratic reaction to any given drug: petechiae from platelet reduction, migraine, worsening of irritable bowel, arrythmias, constipation, icteris, liver tenderness…the list goes on forever.

    We learn our bodies and we gradually become queazy about all drugs. This is a good thing, not bad, generally. Even taking the best and most appropriate drugs for us should be done with a little aprehension and hesitancy.

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