Why good communication between doctor and patient may be bad for patient ‘compliance’

Good communication is, I think, the bedrock of a good relationship between a doctor and a patient. One thing that frustrates some doctors is when their patients do not take their advice. A major gripe can be the failure to take medications as prescribed. In a recent study published in the journal JAMA Internal Medicine, about a third of a sample of patients were found to not be taking their medication as prescribed by their doctor.

The researchers involved in this study were most interested in what aspect of the doctor-patient relationship might influence patient ‘adherence’, and in particular whether the quality of communication in the relationship influenced this [1]. It turns out that patients were more likely to act on their doctor’s advice if they felt their doctor listened more to them and involved them more in the decision-making process. No major surprises here, I think.

I’m all for good communication between doctors and patients, as I alluded to above. I’m also a big believer in we doctors being honest and transparent regarding the likely benefits of any treatment we advise, where this is known. This study actually focused on individuals who were taking at least one medication for diabetes, high blood pressure or ‘raised’ cholesterol.

In the case of cholesterol-reducing medication, we know much about the likely benefits and risks. For example, we know that in individuals with no history of previous heart attack or stroke (as is most likely to be the case), then statins do not reduce the risk of death. We also know that the individual is very unlikely to see benefits in terms of protection from heart attack (studies show that about 1-2 people per 100 benefits here over some years). However, there’s actually quite a good chance (about 20 per cent) that the person will experience one or more adverse effect from the statin including fatigue, muscle pain, liver damage, kidney damage and diabetes. In summary, the reality is the benefits of statins are likely to be outweighed by their risks.

Just imagine, for a moment, what might happen if doctors were to communicate these facts to their patients? I’ve actually had these communications many, many times with people and I can’t recall a single time when someone has still expressed a strong desire to take statins.

I agree that good communication is likely to improve ‘compliance’. However, in the case of statins, I reckon good communication based on the facts would cause adherence to drop like a lead balloon.

The case with statins is not isolated: there’s lots of things that we do and promote in medicine that are not particularly effective, and it’s good to see growing recognition of this. It’s through this sort of debate that we’ll finally see people being able to make truly informed decision about things like prostate and breast cancer screening and whether to take antibiotics for their sore throat. As the information gets out, individuals are becoming increasingly savvy. And the result is people are becoming increasingly less inclined to take their recommendations at face value. Trust me, when people fail to do what their doctor advises, it’s not always a bad thing at all.


1. Ratanawongsa N, et al. Communication and Medication Refill Adherence – The Diabetes Study of Northern California. JAMA Internal Medicine ONLINE FIRST 31 December 2012

7 Responses to Why good communication between doctor and patient may be bad for patient ‘compliance’

  1. mike 18 January 2013 at 8:25 pm #

    Given Dr. Briffa’s stance on statins I have often pondered how he puts his information over, and if there is likely, or has been, opprobrium from the ‘powers that be’.
    There’s probably a whole podcast on the subject, eg are any of his patients on statins (outside of, say, folks with familial hypercholesterolemia or already have had a cardiac event).

  2. Lorraine 19 January 2013 at 12:37 am #

    It’s true, I think more people should be given all the facts known by their doctor as well as reading up on them on their own – then make an informed decision. Statins are a good example.

    I know someone who suffered from bad muscle / joint pain from taking statins and was on the verge of becoming diabetic. She was unable to exercise and had disrupted sleep because of the pain. Her doctor got her to change the type of statin and the dosage a few times which made no difference. She finally decided to see another doctor who agreed to take her off the statins. If she had been told all the facts, she may not have taken statins in the first place.

  3. Stacie 19 January 2013 at 1:16 am #

    Regarding “…already have had a cardiac event.” Even in those instances, statins are useless. Any trial showing a benefit for secondary prevention was done prior to 2005, which was when FDA put new rules and regulations into play. Also consider that those trials , which showed absolute risk reduction for all-cause mortality at less than 2% ( WHOOPEE!!) were paid for, run by, had data analyzed by Pharmaceutical company employees. Since 2005, all statin trials have been negative. So , if you have CAD and want to reduce your risk of events/death, take some omega-3s, which have been shown to reduce cardiovascular and all-cause mortality by more than a pitiful 2%.

  4. Pete 19 January 2013 at 4:51 pm #

    I was very fit until the age of 42 yrs [12 years ago] at which point I suffered a heart attack and had a CABG.

    I was prescribed the usual, statins, aspirin, a beta blocker and a few others meds. All went well for a year or two, the dose of statin was increased at regular intervals until I was taking the maximum of 80mg + Ezetimibe. My cholesterol level would respond initially to the increased statin dose but would then slowly rise again in defiance of the drug.

    I eventually reached a point where the “wheel came off” I had memory problems, muscle pain and fatigue. I did my research and came across http://www.spacedoc.com/ My symptoms matched those associated with statins exactly. I tried every available statin provided by the NHS and at reduced dosages until I finally came off them altogether. I feel better off the statins, but the muscle pain and fatigue remains with me. A private echocardiogram carried out at this time diagnosed mild heart failure, is this thanks to the statins?

    I now have problems with aspirin causing stomach pain, I was prescribed a PPI but this just added indigestion to the symptoms and Pregabalin prescribed for my muscle pain just makes my feet swell up.

    I have reached the point where my entire medicine supply has been consigned to the dustbin.

    What should I be taking? I have no idea and I don’t believe many in the doctors do either. I for one will never again blindly follow the advice of any medical professional, no pill or potion will pass my lips until I have thoroughly checked it out on the net.

    If you think snake oil salesmen died out with Billy the Kid, they didn’t, they are alive and well and still in business in a practice near you.

  5. Dave P 19 January 2013 at 8:13 pm #

    Then i must be one of those this story is about. As a T2 diabetic diagnosed 2000, at my regular assessment the same old line is trotted out regarding Healthy Diet etc etc. In 2007 i was advised by my GP that due to rising numbers my next stop was Insulin Therapy. I discoverd the Lo Carb route and for me it paid off. It is now 2013 and my numbers are still pretty much near normal. I also ditched statins.
    I have lost count of the number of times the GP or Spec Nurse has said We dont advise this route because it is not safe.
    I am sure they mean well but I am testing and eating for me and i know where the evidence takes me.

  6. Lorna 20 January 2013 at 2:42 am #

    When some GPs sit facing a computer and not the patient, it’s not surprising that patients feel alienated from decisions about their health. New Year’s Eve was occasion for another anecdote from a guest who had a 77 year old step-mother who had been prescribed statins for high cholesterol and after months of muscle pain in her legs found herself unable to summon up enough leg strength to get herself out of the bath. Quite scarey for someone living on their own. She has since stopped the statins. Interestingly, the Guardian today carries responses from doctors about when they would not follow the advice of the medical profession. Mammography and steriods appeared but not statins. Still, it is a relief (perversely) to read that even those in the profession have concerns about some treatments and drugs and would not take them for themselves.

  7. jake3_14 25 January 2013 at 2:41 am #

    There is a direct conflict between the authority figure medical schools train doctors to be and the informed patient, who views the doctor as a health consultant. You pay a consultant for their expertise, but you can give material input to their process, and you expect them to incorporate that input. Above all, you reserve the right to ignore their advice. In the medical field, that should be a fairly frequent occurrence, given that the work of John Ioaniddis shows that the quality of most medical research is poor.

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