Adherence: a taste of my own medicine

It started with a routine consultation with my GP on a sunny afternoon. The subject of vitamin D levels came up: “Everyone I test has low levels,” he said, “and I know that you keep out of the sun because of your fair skin, so I’d like to check yours.” I thought nothing of it and presented myself to the phlebotomist a week later. Unsurprisingly, my levels came back well below normal. The GP told me this was easy to remedy: a 12-week course of twice weekly high dose vitamin D followed by daily supplementation. Simple? Perhaps not.

My reaction to this really surprised me. I had originally gone to the GP for an unrelated issue and had come away with a label: “severely deficient”. Why did I need vitamin D anyway? I felt fine. I asked myself what the risks of this kind of deficiency were and realised I did not know. What good would a supplement do me? How would I remember to take it twice a week, let alone forever? A life sentence of daily medication. What was the GP thinking? That was not for me! As questions filled my head and I reflected on my response to the GP’s recommendation, I was struck by the intensity of my feelings and by how disconnected they were from my everyday practice. I spend my days talking to patients about medicines, and had always considered a once-a-day regimen optimal in terms of compliance. Now, here I was “kicking back” and struggling with the same thing.

Foreign concepts

This experience made me reflect on learning I have undertaken over the past three years around supporting adherence and on how much more there is to learn. I had attended a National Prescribing Centre trainer course as part of its “motivation for medicines” programme, where I was introduced to the concepts of supporting adherence and the patient’s agenda. It was my first foray into social pharmacy and I admit to struggling with questions like “how do you feel about taking your medicines?”, which seemed rather woolly. I learnt about addressing patients’ beliefs and concerns related to medicines and supporting them using a “decisional balance”. These were all foreign concepts and it was only with practice and modification to suit my patient cohort of older people, that I started to see the benefit of delving more deeply into this subject.

A short time later I took a coaching course commissioned by NHS London. Although this was directed at performance coaching, using questioning, feedback and exploring the meaning behind behaviours, the overwhelming message was to keep responsibility for any desired change with the person being coached. I immediately saw that these techniques could be applied in a health setting and I began to use them to support adherence. It quickly became clear that the approach to patient counselling I had taken for most of my pharmacy career was more paternalistic than I had realised.

Imparting key safety information around medicines use is a prime feature of supporting patients with medication and is critical to safe use of medicines, but I struggled to see how this could fit with the benefits and concerns discussion and keeping responsibility for medicines with the patient. I am the first to admit that I was sceptical about trying this approach but I was convinced enough of the importance of real patient engagement to try.

I built on the skills from the NPC Plus course and began to integrate my coaching skills into conversations about medicines taking. It takes more time than the traditional patient counselling that I learnt as an undergraduate but this more questioning approach made me aware of issues that I would not have uncovered with a traditional approach.

I built on the skills from the NPC Plus course and began to integrate my coaching skills into conversations about medicines taking. It takes more time than the traditional patient counselling that I learnt as an undergraduate but this more questioning approach made me aware of issues that I would not have uncovered with a traditional approach.

This consultation illustrates how we can influence patients’ control of their long-term conditions by providing practical advice (information support) and understanding that, for effective change, they must own the change. The coaching approach allowed the patient to come up with a solution she could manage and I could support her with my pharmaceutical knowledge. Discussing benefits and concerns, together with supporting patients in being responsible for their own health management through medicines, is a practical and effective way to support adherence.

New medicine service

The recently announced new medicine service tasks pharmacists to identify patients in certain groups to support them in medicines taking and guidance is being provided on how to engage in this type of interventions[1]. As part of this new service, we may all wish to improve our skills in the area of adherence and National Institute for Health and Clinical Excellence adherence guidelines support this[2].

Pharmacists are ideally place to improve the health of patients with long-term conditions, supporting not only medicines management but also the wider public health agenda. By encouraging patients to take and retain responsibility for their own health, including medicines taking, we are promoting long-term adherence to health and medication related initiatives, working towards better health.

Readers might be wondering how I chose to manage my vitamin D deficiency. I returned to my GP and we negotiated: he found it hard to believe that I did not want a 12-week course as a loading dose but I discussed alternatives with him and we agreed on a higher dose over a shorter time. As for the daily medication, I could not handle the idea of a pill a day for life. I suggested a monthly regimen, which I am confident I can adhere to. The GP was sceptical but agreed. After all the adherence advice I have given to my patients, this really is a taste of my own medicine, but I am confident because I have decided how and when to I can take my vitamin D: a dose on the day each month that I top up my telephone.

References

1. NHS Community Pharmacy Contractual Framework — summary of service developments in 2011/2012. Available at www.psnc.org.uk (accessed 10 June 2011).

2. National Institute for Health and Clinical Excellence. Involving patients in decisions about prescribed medicines and supporting adherence CG76 NICE medicines adherence January 2009. Available at http://guidance.nice.org.uk (accessed 10 June 2011).