Recommendations seem to revert to traditional approach
Editor - Yamey, in his article on looking after patients who will not look after themselves, advocates the move towards the use of concordance, rather than compliance, in the doctor.patient relationship.1 We wish to raise several points with regard to this article.
Primarily, many patients do not fail to take advice or medication but actively choose not to do so, often for various reasons. Therefore, when Yamey talks about the failure of patients to take medical advice and of doctors wanting patients to adhere to regimens he contradicts his original aim of promoting a therapeutic alliance. Instead, the image of an obedient patient is maintained as being desirable.
Yamey also gives an ambiguous account of concordance by characterising all "non. compliant" patients as "self.neglecting" and "not caring for themselves." This characterisation does not distinguish between patients who, for whatever reason, are unable to look after themselves and those who choose not to follow medication regimens or advice. The needs of these groups may differ in terms of whether they require assistance in taking prescribed medication or whether more collaboration is necessary between health professionals and patients in order to adapt prescribed treatment to the needs of the individual. It is also important to recognise that there are different ways in which patients do not follow treatment regimens. for example, they may modify the treatment by taking their tablets only when they feel it is necessary, or by altering the timing of doses to suit their lifestyle.2
Although Yamey proposes several practical methods for encouraging patients to take medication, these suggestions are based on the assumption that patients will actually take their medication. The challenge of promoting concordance begins before this, when the patient decides whether or not they will follow the treatment plan. Looking at the implications of the treatment from the patient's perspective, or giving patients the opportunity to discuss concerns and beliefs about illness and treatment with a doctor or other healthcare professional may prove to be useful in terms of increasing concordance. Yamey attempts to promote the move towards an equal decision making process between doctor and patient, but this aim becomes lost in his recommendations, which seem to revert to the traditional approach of maximising patient compliance.
Helene Mitchell, research assistant
Kelly Vincent, PhD student
Katharine Stowers, research assistant, Department of Rheumatology, GkT Medical School, king's College hospital (Dulwich), London, SE22 8PT
studentBMJ 2000;08:89-130 April ISSN 0966-6494
- Yamey G. Looking after patients who won't look after themselves. studentBMJ 2000;8:17.8. (february.)
- Hunt LM, Jordan B, Irwin S, Browner CH. Compliance and the patient's perspective: controlling symptoms in everyday life. Cult Med psychiatry 1989;13:315.34.
