Not to be taken as directed
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7385.348 (Published 15 February 2003) Cite this as: BMJ 2003;326:348
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Editor –
The editorial of 15 February, 2003 (1), discussed the
concept of concordance - "the creation of an
agreement that respects the beliefs and wishes of the
patient" and also stated that "when the medicines that
doctors prescribe fail to produce benefit they expect,
they often respond by…selecting an alternative
medicine".
On May 1, 2003, a report entitled "Complementary and
Alternative Medicine: the consumer perspective) was
published by the Prince of Wale’s Foundation for
Integrated Health within its occasional papers
series(2). This report was funded by the UK
Department of Health and demonstrates just how
widespread the current choice by the British public for
complementary and alternative medicine (CAM) is.
The report summarised the findings from the three
main British based surveys on CAM use
(3,4,5).Additionally, a seven month search was
launched to uncover formerly unpublished material
about consumer preference for CAM from all over the
UK. Over 50 additional theses, internal reports,
unpublished papers and World-Wide-Web based
publications were added to the report. This material
spanned the years from 1988 to 2001.
The results of this report might be briefly summarised
as follows(2):
Eight types of CAM were indicated as the most
commonly utilised. These were: acupuncture,
aromatherapy, chiropractic, homeopathy, hypnotherapy,
herbal medicine, osteopathy and reflexology. The
survey of most commonly utilised therapies also
highlighted a need to distinguish between practitioner
based therapies, over the counter medication and self
practised therapies such as yoga and meditation.
The major presenting conditions for CAM use were
found to be musculo-skeletal problems especially of
the neck and back , injuries, bowel problems,
indigestion, mental health problems (specifically,
stress, anxiety and depression), migraine and asthma.
In addition, life-style use (such as for the purposes of
the maintenance of well being) was also found to be a
significant reason for CAM use. Poor outcomes from
conventional allopathic medical treatment, experiences
of adverse effects from pharmaceuticals, negative
experiences of the patient-doctor relationship and
health beliefs which were not in keeping with the
allopathic medical models were also reasons for CAM
choice.
Women were found to be greater users of CAM than
men, both in terms of practitioner interventions and over
the counter purchases of homeopathic and herbal
remedies. This was found to be broadly similar to the
pattern of female use of GP and outpatient services.
CAM users were also most likely to fall within the 35-44
age group. In terms of social class, those from groups
AB (professional and white collar workers) and C1
(clerical, junior managerial and administrative workers)
are more likely to be users of CAM while those from
groups C2 (skilled working class) and DE (unskilled
and manual workers) were more likely to be non-users.
This profile applies in a setting where the majority of
CAM use is paid for out of pocket and are therefore
more likely to be utilised by people with sufficient
disposable income.
Stringent estimates of use suggested that between
6.6% and 20% of the population has utilised CAM in the
previous 12 months. The average number of visits to a
practitioner ranged from 2.8 to 5.3 per year, leading to
an extrapolation that around 5.3 million people aged
over 18 made 31.7 million visits to practitioners of the
eight most popular CAM therapies in the previous 12
months. There were also indications that the use of
CAM had risen between 1993 and 1998. Excluding over
the counter use of CAM products, lifetime use of any of
the eight most popular CAM therapies was estimated to
be 32.1%. This estimate rose to a figure of 46.6% if
over the counter products were included in the
equation.
Currently 79% of CAM is paid for directly by the patient
with a mean expenditure calculated at approximately
£13.62 a month. The NHS accounts for around 10% of
consultations at an estimated cost of £50-55 million in
2001. Total expenditure for consultations with CAM
practitioners was estimated at £580 million. However,
other estimates suggested that with the inclusion of
over the counter products, expenditure could be as high
£1.47 billion per annum.
Clearly the use of CAM is neither peripheral nor "fringe"
within the UK today. The high levels of consumer
investment and interest in CAM suggest that the
evidence base for CAM needs to be urgently addressed
and expanded, in the interest of patient safety.
Therefore, more investment in CAM clinical and basic
scientific research is required. This report also
deserves attention because it voices a consumer
opinion of modern health care and highlights a vote for
a diverse system of health care which promotes greater
human contact between patient and healer. This will
have implications for the way in which a responsible
consumer of healthcare interacts with their GPs to
appraise options and alternatives which appear to be
here to stay. Putting concordance into practice does
indeed appear to be key for the future of a modern
pluralistic system of healthcare.
Chi-Keong Ong, MSc., PhD.
Mansfield College, University of Oxford
Michael Fox
The Prince of Wale’s Foundation for Integrated Health
1. Marinker M and Shaw J. Editorial: Not to be taken as
directed. BMJ 2003, 326:348-349.
2. Ong CK and Banks B. Complementary and
Alternative Medicine: the consumer perspective.
Occasional Papers No. 2 (2003). The Prince of Wales’s
Foundation for Integrated Health: London.
3. Thomas KJ et al. Use and expenditure on
complementary medicine in England: a population
based survey. Complementary Therapies in Medicine
(2001) 9: 2-11
4. Ernst E and White A. The BBC survey of
complementary medicine use in the UK.
Complementary Therapies in Medicine 2000. 8: 32-36
5. Ong CK et al. Use of complementary and alternative
medical services in England: A population survey of
four counties 1997. American Journal of Public Health
(2002), 92:1653-1656.
Competing interests:
None declared
Competing interests: No competing interests
Sir: Whether at any time doctors' orders have been followed is open
to debate. The very term suggests a degree of contempt. With political
correctness having moved the term from this to compliance, then adherence
and now concordance, may reflect the seriousness, or lack thereof, with
which our instructions are taken. More basic than how much patients value
the instructions given to them by medical practitioners, may be the belief
patients' attribute to the physicians directions. Coming at the problem
from another angle one might wish to consider to what extent patients
believe how much the disease that doctors label a patients illness with
accords with their own perceptions of their problem.
Certainly, in
psychiatry particularly, this element of 'insight' is a major determinant
of so called lack of concordance. Were more time spent in trying to
explain to patients the nature of their problems, as seen through a
doctors eyes, a more reliable uptake of advice might be expected. To
anticipate an improvement in this area, within the shortsighted government
encouragement of doctor bashing, internet misinformation overload and
sensationalisation of medication side-effects, is probably overoptimistic,
but still worth trying.
Competing interests:
None declared
Competing interests: No competing interests
Concordance is the key word for successful treatment nowadays. Most
of our patients today are health-educated, health-concious and
enlightened. For prescriptions to be followed, the patients have to be
taken into confidence first. If the confidence is won, concordance will
follow. It has been rightly said, 'Medicine is Science, but treatment is
an Art". If we can master this art properly, then concordance should be
well managed and emphasized, thereby resulting in better
compliance.Placing one self in the patient's position, thinking of
whatever queries can creep into the mind of the person on the other side
of the table and trying to answer them in a truthful manner should see us
through.
Best regards.
Dr. M. Mukherjee, MD.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
The issue of concordance is an important one.The authors state:"...we
must learn to create robust therapeutic alliances with mutual respect for
the both the doctors professional opinion and the patients personal
decisions..." As is fairly usual in medicine, we are given hints about
what to do and why to do it. What is left out is HOW TO - the process.
The field of Neuro-linguistic Programming (NLP) is the study of HOW
people do what they do - the structure of subjective experience. In the
book Consulting with NLP (1) I detail not only how patient's structure
their health beliefs and expectations, but also how to communicate
effectively using their own decision making strategies.
Utilising just how this particular patient consulting today convinces
himself to actually take action we can formulate our communication in such
a way that it makes complete sense to the unique individual sitting in
front of us. If we do it wrong they may not "see what we are saying", it
may not "sound right" nor even "feel right".
Our job as effective communicators is to get the message across
respectfully and with empathy so that it fits their own decision
strategies like a glove. NLP will give you lots of helpful hints.
Sincerely,
Lewis Walker FRCP
Ref (1)Walker, L (2002) Consulting with NLP: neuro-linguistic
programming in the medical consultation. Radcliffe Medical Press
Competing interests:
I am the author of the quoted book
Competing interests: No competing interests
one frustating feature of medical practice if poor patient
compliance.i find many reasons for these:
1.large number of tablets: if the number is large, compliance is going to
be poor. under the circumstances, one should select longer acting drugs
and fewer dosing and
also combinations may be resorted too. for instance a combined preparation
of atenolol with amlodipine will give better compliance than prescribing
them
separately. a good test is ask " can i take so many tablets myself?" if
the answer is no, improvise the prescription.anti-tubercular drugs also
produce poor compliance, but the kit preparation are more successful.
2.unnecessary drugs: cut down on multivitamins, anti-allergics for common
cold, fish oils and anti-oxidants, vit c, cough syrups etc.
3.side effects: the doctor may be required to change the family of drugs.
for instance enalapril produce cough and amlodipine pedal edema. both
these may produce poor compliance. losartan is almost free of cough, and
lercanidipine less of edema.
4.poor patient awareness: another cause of discontinuation is patient's
beleif that treatment is temporary. most patients discontinue anti-
hypertensives or anti-diabetics because they feel better. it is necessary
to educate them that there is no cure for many of the so called modern
diseases and a life long commitment is required by the patient.
5.aversion to allopathy: some patients have either genuine or misguided
aversion to allopathic grugs. they prefer herbal or homeopathic drugs.
here you cannot do much except request the patient to do the necessary.
there is little to be gained in belittling other alternative forms of
therapy, including acupuncture, faith healing etc.
it is said that a doctor's prescription tells more about the doctor rather
than what his patient is suffering from.we must remind ourselves not to
make the treatment
worse than the disease.
Competing interests:
None declared
Competing interests: No competing interests
Overhaul required of licensing rules for medication
Overhaul required of licensing rules for medication
A vigilant pharmacist made me aware on 10th July that AstraZeneca had
announced the discontinuation of Mysoline affecting tens of thousands of
patients in the UK. Supplies would dry up from December 2003. Imagine
the shock when you’ve used it for over 20 years and learnt numerous
patients have been unable to wean off it in over 40 years.
AstraZeneca PLC
The directors of AstraZeneca(Global) deemed Mysoline a low volume
usage product so suddenly, epilepsy control for many is in jeopardy.
AstraZeneca have a mission statement which refers to global responsibility
for consistently high standards of behaviour worldwide:-
Yet, no measures were taken to mitigate the impact of this decision
by ensuring:
Continuity of supply by another firm,
All affected patients had seen a specialist with a way
forward in place
Recognising it takes upto 18 months to wean off
Medicines and Healthcare Regulatory Authority
The MHRA sanction the discontinuation of medication in an ‘Ivory
Tower’ with none of the aforementioned measures implemented. They state
“companies cannot be forced to produce medication”.
Summary
The Terms and Conditions behind licensing companies to produce and
sell medication in the UK need tightening up. They can’t just stop
supplying for economic reasons when it is so life-affecting and takes so
long to come off. They must carry a ‘behavioural responsibility’ to
ensure all those using their products have consulted a specialist and a
way forward is in place.
It is impossible to measure the cumulative stress caused and time
taken up of so many people's lives. An holistic approach is required to
ensure patients don't get subjected to this sort of situation again. Next
time, it might be something life saving, not life-affecting.
Competing interests:
None declared
Competing interests: No competing interests