GETTYSBURG MEDICAL NEWS
The Clinical View
By P. E. Hoffsten, M.D.
3 October 2007

THE PROBLEM OF COMPLIANCE

            The gentleman was a 40 -year-old divorced salesman who spent a great deal of time “on the road.”  The company he worked for had a health insurance policy that covered a “40 -year-old checkup.”  He had been an athlete in high school and still played tennis occasionally.  He had never been in a hospital and took no medications.  As far as he was concerned, he was a picture of health.  But his company suggested that a health checkup was a good idea and so he thought since it was free he would come in for the checkup. 

            On physical examination, he was completely normal and really had no health habits that were detrimental, but his family history was provocative.  His father had had a heart attack at 52-years-of-age and one older brother, aged 48, was taking cholesterol medicines.  His mother had  hypertension as did two of his sisters, aged 46 and 50. 

            His blood tests returned showing a total cholesterol at 280 milligrams percent (normal value less than 200).  His bad cholesterol was 175 milligrams percent (normal value less than 100, preferably less than 70).  His good cholesterol was only 25 milligrams percent (preferred value greater than 45).

            I reviewed these values with him and after noting that his blood pressure was 135/85 mm Hg  (prehypertensive), I indicated to him that it would be in his interest to get on medication to treat his hypercholesterolemia and to watch his blood pressure very closely for any drift into higher values.  His family history, as mentioned, was very provocative. 

            I gave him samples of a “statin drug” and instructed him to return in about a month for a follow- up value regarding the effectiveness of the statin drug and any side effects that might be occurring.  On his return, the total cholesterol was indeed under 200 and his bad cholesterol had dropped to only 85, a very favorable result from the medication.  I called the prescription for the statin drug to his pharmacy of choice and indicated we should recheck in a year.  I pointed out that the most effective medications a person takes are those early in a disease process so that the condition never results in a heart attack or a stroke.  He said he understood.

            That was five years ago.  He returned to the clinic this past week because he had been to a screening clinic and found that his cholesterol was very high, now at 310 with a bad cholesterol of 180.  He said they also noted that his blood pressure was elevated at 145/90.  He wondered what he should do.  I didn’t know whether to laugh or to cry, but recognizing both were unprofessional, I did neither. 

            I asked why he had not continued the medication he had been given several years ago and why he had never returned as directed.  He said he had filled the prescription once or twice, but then got busy and forgot to fill the prescription and just quit taking the medicine.  He said he was feeling good so he didn’t really need to check his blood pressure.  He did add that his mother, now in her 70s, had recently had a stroke. 

            This gentleman would be described in medical terms as having non-compliant behavior.  That term is offensive to many and the preferred politically correct term is “non-adherent behavior.”  Whatever, it simply means he was given advice to take a medication or to follow some other health practice that is pretty clearly indicated to his benefit and yet he simply doesn’t follow the advice given.  Healthcare professionals struggle with the reason individuals are non-compliant.  It is not like this is a simple problem.  Surveys done show that with cholesterol medications, only about one third of the patients that ever start them are still taking them a year later.  The sad situation is that in order to keep the cholesterol down, the medication does have to be continued.  This is true for cholesterol medications, blood pressure medications, heart medications, diabetes medications, tuberculosis medications, and the list goes on and on.  With apologies to the public, this concept of how to treat chronic disease is what we have so far.  Medical science hasn’t come up with a one pill one time cure.

            The characteristics of individuals prone to non-compliance include: men more than women, younger more than older, single rather than married, and less educated rather than more educated.  The gentleman above fulfilled all of those criteria as he proudly professed that he had dropped out of high school and still had been a very successful salesman.  Other impediments to medication use include the high cost, the perception that the medications cause side effects, and most importantly that a medication is for long-term avoidance of future complications.  A medication taken today to stop a heart attack in 20 years doesn’t sell very well.  A medication prescribed today to stop a pain the person has right now sells pretty well.  Medications that require more than once a day use are almost never adhered to over an extended period of time unless that medication provides an immediate relief of some symptom.

            The healthcare professionals at your local clinics take care of a wide variety of problems, but most of the time spent with adults is usually addressed to preventive medicine trying to avoid future catastrophes.  There are excellent medications available to head off heart attacks, strokes, diabetes, hypertension, and even the severe epidemic of overweight in our country today.  The major reason why these medications do not work is non-compliance.  Try as healthcare professionals will, we still haven’t worked out the compliance problem.  We need the patient’s help and perhaps more help from the news media and their stopping their medical terrorism.