When the Public Loses Faith In Physicians

By David J. Gibson, MD

More than half of American adults forgo treatment recommended by physicians, at a staggering cost to the health care system.

TECTONIC SHIFTS IN OUR SOCIETY have generally been mind-numbingly slow.

For the past decade, fundamental shifts in our society on how we perceive and pay for health care have unfolded in moves measured in microns.

Then, without anticipation, a moment of clarity strikes. It leaves a smell of ozone in the air, like the aftermath of a bolt of lightning. You can then comprehend with clarity disparate trends that previously seemed unrelated.

The Wall Street Journal Online/ Harris Interactive health-care pollą published in September of 2005 left the smell of ozone. The poll reported some disturbing information about the evolving relationship physicians have with the American public.

More than half of U.S. adults say they have chosen to forgo a treatment recommended by their doctor, including filling a prescription, getting a diagnostic test or undergoing a surgical procedure, because they felt it was unnecessary or too aggressive.

The online poll of 2,286 adults found considerable concern among Americans about the frequency with which they receive too many, or overly aggressive, treatments from their doctors: 83 percent felt under treatment often or sometimes can result in medical problems among patients, while 72 percent feel over treatment contributes to problems.

The remaining part of the poll had multiple responses (so totals add up to more than 100 percent). Of the respondents, 32 percent reported not filling a prescription because they felt it was unnecessary. Another 21 percent said that they had chosen to get a second opinion because they lacked confidence in their doctors' recommendations.

What did patients think was behind the perceived over treatment or overly aggressive treatment?

Highest on the list were physicians' concerns about malpractice (53 percent), their desire to earn more (45 percent), their desire to meet patients' demands (45 percent) or to make fast and easy decisions (31 percent). These are seen as the main causes of unnecessary care, according to the poll.

Another 30 percent blamed aggressive treatment on misleading information doctors receive from drug and medical device companies, 27 percent thought it resulted from a faulty medical diagnosis, and 16 percent said it was "to give patients more reason to hope."

As the above demonstrates, when patients lose confidence in their physician, non-compliance results. Two major factors determine the outcome of medical care rendered to patients. One involves the decisions made by physicians in determining the components of the treatment. The other concerns the decisions made by the patient in carrying out the treatment.

Approximately 50 percent of the medications written for chronic disease states are never picked up and over 66 percent of patients fail to comply with their doctors' orders.

Poor compliance is a leading cause of failed medical treatment, but even skilled professionals often miss detecting it as the reason for treatment failure.

Poor compliance occurs in virtually all fields of medical care, including organ transplant management, oral contraception, hormonal blockade to prevent recurrent breast cancer, anti-viral treatment of AIDS, and blinding glaucoma - where many assume strong motivation would ensure good compliance.

According to the literature, up to one-third of patients always comply, one-third of patients sometimes comply, and one-third of patients never comply.

In this environment many physicians assume that the patient complied but did not respond, so they escalate doses or prescribe additional drugs. The clinically prudent step is to use confirmation of dispensing data, not assumptions, to guide prescribing.

Although the importance of improving patient compliance is universally accepted, a number of barriers often prevent physicians from incorporating the necessary strategies to help their patients comply with prescription directions or lifestyle recommendations.

One of the fundamental problems is structural. America's health care system is geared toward responding to patient complaints or highly acute conditions. The current system has very few resources that will cue the physician that something needs to be done. Furthermore, there is no feedback loop to alert the physician if the patient ignores or modifies the course of therapy prescribed. To increase patient compliance, we need to find ways to implement cues, reminders and feedback loops in the systems to help physicians address this problem.

In the ambulatory environment, the failure of patients to follow medical recommendation causes over 125,000 deaths each year. It also increases hospital utilization (10 percent of all hospital admissions and almost 30 percent of admissions to nursing homes are due to improperly taken prescription medications).

The annual cost of patient noncompliance in the United States, including the resulting costs for deaths, workdays lost, hospital and nursing home admissions, and the cost to treat adverse drug reactions is estimated to be $100 billion per year in the United States.

It is also conservatively estimated that 20 to 25 percent of employers' health care expenses may result directly from patient non-compliance. Nationally, the added liability relating to pharmacy alone may total up to another $300 billion a year in increased health-care expenses and absenteeism.

There are real consequences to the evolving lack of confidence our society is expressing toward physicians. This lack of confidence needlessly increases the overall cost of health care. It makes our role as the patient's advocate tenuous and opens the door for other interested groups to fill the evolving confidence void. As a profession, we ignore evolving trends at our own peril. There is no substitute for spending the needed time with patients to overcome their fears and build confidence in our recommendations. The following reality is now inescapable: compromising our independence to pharmaceutical companies, insurance companies, medical groups or hospitals has damaged our standing before the only audience that counts - the American public. In short, we must earn what we took for granted in the past or get used to the smell of ozone.