Coming to an understanding with patients and prepositions

Editor—The translation of the phrase from Franz Kafka's short story A Country Doctor at the beginning of Marshall Marinker's personal paper should read: “To write prescriptions is easy, but to come to an understanding with people is hard.” 1 It is unlikely we will ever come to an understanding of people; coming to an understanding with them, though difficult, is at least feasible and, in any case, entirely in the sense of Marinker's article. It is worth observing that the reflexive German verb sich verständigen puts the onus on the pronominal subject–that is, the doctor–to make himself or herself understood in a more subtle way than that conveyed by the gesticulating of the English prepositional construction. Interestingly, the doctor in Kafka's story2 –first published in 1919 and based on his own favourite uncle Siegfried Löwy–tries very hard indeed to “concord” with his patient's health beliefs. So hard does he try, in fact, that he is stripped naked, thrown into bed with the patient, and then undergoes the final indignity of being hounded out of the village for not coming up to expectations. Kafka, a noted hypochondriac, craftily omits to tell us what those expectations might have been.

Treating the patient as a decision maker is not always appropriate

Editor—Non-compliance with prescribed drug regimens is high (around 50%) and limits the benefits of current medical care.1 The costs of not taking drug treatment in terms of persistent disease and increased mortality are thought to be enormous but are largely unreported. The Royal Pharmaceutical Society of Great Britain has addressed this important issue in its recent report2; but is changing the terminology from compliance (meaning yielding, complaisance, submission) to concordance (agreement, harmony) sufficient to change behaviour as suggested by Patricia Dolan Mullen?3

Discussing the pros and cons of drug treatment with the patient before prescribing it is good medical practice. There are, however, at least three situations when treating the patient as a decision maker–the backbone of the concordance model–will fail.

Firstly, if compliance is incomplete during clinical trials of new drugs conclusions about effectiveness and dose may be inaccurate because such trials require almost complete compliance and adherence to strict protocols. Incomplete compliance may thus lead to abandoning a useful treatment or to toxicity in patients who adhere to the prescribed dose.

Secondly, compliance and non-compliance are patterns of behaviour resulting from a complex interaction of many different factors. For example, there is a high degree of association between non-compliance and depression. Attempts to change behaviour with cognitive analytic psychotherapy are encouraging and suggest improvement in both compliance and clinical parameters in patients with asthma.4 Thus, research into the human behaviour of medicine taking is related to com-pliance and does not fit the concordance model.

Thirdly, in the case of an infectious and potentially lethal disease such as tuberculosis, can we as doctors ethically allow a patient the freedom of deciding which if any of the antibiotics he or she will take and how much? Patients with open pulmonary tuberculosis who decide not to take drug treatment will remain infectious and a hazard to others. Furthermore, patients who are selective about the antibiotics or erratic in taking the treatment risk developing multidrug resistant disease, a condition that is difficult and costly to treat and usually fatal to immunocompromised people. Doctors already impose their will on these patients by prescribing combined preparations and rigorously supervised regimens, with treatment being directly observed when poor compliance is suspected.5

The change in approach from compliance to concordance may have implications beyond the treatment of an individual patient.