Patient Compliance Big Picture
Editor | On 07, Oct 2018
We first wrote about patient compliance via a very specific case study some time ago (Reference 1). Reading Jordan Petersonâ€™s book, â€˜12 Rules For Lifeâ€™ (Reference 2), recently triggered thoughts about the bigger compliance issue. Specifically, his second Rule, â€˜Treat yourself like someone you are responsible for helpingâ€™, which begins with the apparent paradox that a patient who has just received a kidney transplant and needs to take drugs to ensure his body doesnâ€™t reject the new organ is less likely to comply with his medication than he would be to comply with the medication prescribed by his vet for his sick dog. Petersonâ€™s overall conclusion is that we tend to possess a hidden belief that â€˜weâ€™re not worthyâ€™ of being saved. To be honest, the conclusion felt somewhat counter-intuitive. Counter-intuitive enough for us to instigate a piece of research of our own.
Lots of smarter people than us have, over the years, done analyses to try and get to the â€˜root causeâ€™ of patient non-compliance. The reason the compliance problem feels no closer to being solved today than it was when medicines first appeared in the world, is probably because all these smart people â€“ Peterson included â€“ operate from the mis-conception that any kind of complex problem can have a â€˜root causeâ€™. As weâ€™ve been saying for many years now, there is no such thing as a root cause when the problem is complex. Rather, the problem may be seen to be an emergent property of a conspiracy of causes.
We decided to make a trawl through the literature to find as many â€˜root causeâ€™ definitions as we could. We ended up with 57. The results of the findings are summarized in Figure 1:
Figure 1: List Of Reasons Patients Give For Not Complying With Medication Regimes
After uncovering the 57 unique explanations for the non-compliance problem, fairly obviously, our next step was to construct a Perception Map in order to better understand the relationships between each of them.
The resulting map indicated three independent themes. The first, and biggest of these themes is illustrated in Figure 2:
Figure 2: Patient Non-Compliance Loop 1 â€“ Control/Guilt
The downward-spiral representing loop illustrated in this map is all about our inborn desire to be â€˜in controlâ€™, leading to occasional compliance lapses, which in turn lead to guilt and then back to a bigger reminder of the feeling of not being in control. Interesting, too, to see the Jordan Peterson Rule-2 as one of the two drivers of guilt, the other â€“ bigger â€“ driver being denial or trivialization of symptoms.
All in all, it is difficult to see much evidence within the overall healthcare sector that anyone is seriously tackling these issues. Especially in light of the fact that when any of us steps over the threshold of any kind of medical facility, we inherently put ourselves under the control of others. It is not our intention to trivialize the problem here with glib answers â€“ this is a big systemic issue that feels like it needs a portfolio of contradiction-breaking solutions. That said, it seems like the Perception Map hints that Petersonâ€™s Rule 2 suggestions offer up a solution means suitable at the individual levelâ€¦ provided the patient is prepared to be honest with themselves about their symptoms.
Moving on, the fact that the map reveals second and third independent themes should tell us that Petersonâ€™s â€˜root-causeâ€™ diagnosis might well be â€˜necessaryâ€™, but that it canâ€™t be â€˜sufficientâ€™. Figure 2 shows the second theme â€“ this time a downward spiral loop relating to patient fears of addiction and diminishing drug efficacy the more the duration of usage is maintained.
This is another enormous issue. For the pharmaceutical industries at least, who, it may be seen have something of a vested interest in preserving this downward spiral, since, for them, it can easily look like a very virtuous-cycle means of continuing to sell lots of drugs. Thereâ€™s not much that an individual patient can do to mitigate this downward spiral. Its presence in the map seems indicative that people publishing their thoughts on the compliance problem have tapped in to something that people â€“ in the West at least â€“ kind of instinctively know: taking drugs means we are tampering with the human bodyâ€™s natural â€˜self-organisingâ€™ capabilities.
Figure 3: Patient Non-Compliance Loop 2 â€“ Addiction/Diminishing-Returns
We get to see another version of this â€˜tamperingâ€™ problem in the third Map theme, as illustrated in Figure 3:
Figure 4: Patient Non-Compliance Loop 3 â€“ Guessing/Non-Holistic
This downward-spiral representing loop is the most complicated of the three. Looking at the sequence of five perceptions in the loop reveals the story of a growing awareness that â€˜modernâ€™ (Western) medicine is very symptom-focused and thus, thanks to the Internet and the propensity to use it as a first port of call, and the likelihood that we will find multiple conflicting remedy suggestions leads to a lack of confidence in doctors. Which then, in turn, leads to patients increasingly likely to experiment, which then leads to a broader range of alternative therapies being tried, which then leads to the aforementioned growing awareness that treating symptoms rather than causes is not a good thing.
This is perhaps the most pernicious of the three themes, suggesting as it does, that the whole medical (Western â€“ again) profession is in need of a major step-change. A step-change that necessitates a root-and-branch re-invention of the whole system, starting with the ways in which new doctors are educated. The healthcare sector is structured around a suite of specialties, few of which ever get to interact with the others, and as a result, the patient never gets to receive treatment (or preventative advice for that matter) in which all or even some of the dots are connected.
While anyone in the SI team is taught and believes that â€˜all problems are solvableâ€™, we also know that the constraints that get imposed on problems can also very easily make them unsolvable. Patient compliance, in other words, is a very solvable problem. Provided the whole healthcare domain works together to solve it. And therein lies the rub â€“ the healthcare domain not only doesnâ€™t work together, it currently has no incentive whatsoever to learn how to work together. Specialists educate more specialists; drug companies need to keep selling drugs to stay in business. And meanwhile, you and I, the poor patient is caught in a psychological guilt trap.
What the three themes says to us here in SI-Land is that all attempts by the healthcare â€˜systemâ€™ to solve the patient-compliance problem are doomed to failure until such times as the â€˜systemâ€™ is willing and able to re-invent itself. Thatâ€™s a Level 5 Innovation Capability Maturity job. Sadly, there are no players in the healthcare sector with anything better than Level 2 capabilities at the moment.
Which leaves major disruption from outside the â€˜traditionalâ€™ boundaries of the current system as the most likely hope.
While there are some signs that this (AI-driven) disruption is on the way, it doesnâ€™t offer up much hope for todayâ€™s patients and their struggle to comply with the medications theyâ€™re having prescribed. For individuals to battle the â€˜systemâ€™ single-handed is a pretty big ask. From my perspective, the most pragmatic advice seems like it comes from the growing AntiFragile movement (Reference 3): prevention is better than cure, and the best way to prevent is to periodically stress the body to trigger the self-repair mechanisms it possesses. Then, if we do reach the symptomatic stage of an illness and things are serious, eliminate feelings of guilt, and attack the problem with as many strategies as you can.
- Systematic Innovation E-Zine, â€˜Case Studies: Patient Compliance Improvementâ€™,Â Issue 147, June 2014.
- Peterson, J.B., â€™12 Rules For Life: An Antidote To Chaosâ€™, Allen Lane, 2018.
- Taleb, N.N., â€˜Antifragile: Things That Gain From Disorderâ€™, Penguin Random House, 2012.