Patients often find it hard to keep to a long-term treatment plan, but there are ways physicians can help
“Medicine is not merely a science but an art,” the Renaissance physician and philosopher Paracelsus once said. “The character of the physician may act more powerfully upon the patient than the drugs employed.”
That observation from 600 years ago remains true for today’s primary care doctors, particularly when it comes to helping patients manage chronic diseases. A doctor may understand the science behind treatments for diabetes or hypertension. But that knowledge does little good unless the patient sticks to a plan for managing their disease, whether it is exercising more or remembering to measure and record blood sugar levels. That is where the art of medicine comes in.
“Physicians spend all this time getting educated, but we also have to be conscious of whether we’re talking to patients in a way that connects with them,” says Dustin Arnold, D.O., an internist who has practiced in Cedar Rapids, Iowa, for 25 years.
Chronic diseases a growing problem
The need for patient adherence to treatment plans has never been greater — chronic diseases are becoming more widespread and deadly. According to the Centers for Disease Control and Prevention, in 2018 nearly 52% of adults had at least one of the 10 most commonly diagnosed chronic conditions, and about 27% of adults had multiple chronic conditions. The latter percentage was up from about 22% in 2001.
Similarly, a 2022 study from the National Center for Health Statistics found that mortality rates for several common chronic diseases, including heart disease, chronic lower respiratory diseases, diabetes, chronic liver disease and kidney disease, increased from 2020 to 2021.
At the same time, physicians confront a growing array of obstacles to helping patients follow treatment plans, such as shorter appointment times, the spiraling costs of prescription drugs, and patients whose insurance coverage is inadequate for their health needs.
All this is in addition to the ever-present challenge of coaxing patients to change lifelong behaviors that may have caused, or exacerbated, the disease in the first place — never an easy task.
Helping patients understand disease and its management
Faced with these difficulties, how can primary care doctors best help patients adhere to a plan for managing their chronic disease or condition? Those experienced in treating such patients say it begins with ensuring the patient understands the disease and how and why it needs to be managed.
“The most essential first step is making sure the patient understands the rationale and importance of the treatment plan,” including the potential consequences of nonadherence, says Ryan Mire, M.D., MACP, an internist in Nashville, Tennessee, and president of the American College of Physicians.
“To be able to explain to them why they’re taking these medications or on this type of diet, why they have to lose 20 pounds, it all plays a big role in getting patients to buy into their health care,” adds Daron Gersch, M.D., FAAFP, who practiced family medicine in Long Prairie, Minnesota, for 25 years.
Sometimes a patient’s lack of understanding of what is required to adhere to a plan is masked by their eagerness to appear on board with it and to please the doctor, says Teresa Lovins, M.D., FAAFP, a family physician in Columbus, Indiana.
“Patients are so agreeable most of the time that when the plan comes up, they’re like, ‘Yeah, I can do that.’ Then reality sets in when they get home that they have to do breathing treatment or use their inhaler several times a day and they didn’t realize what that really entails,” Lovins says.
Building long-term relationships
Along with educating the patient, it is vital to establish a long-term relationship, doctors say. Doing so not only builds trust, but it also often reveals clues as to what motivates the patient — a crucial part of coping with chronic diseases.
“What I teach residents and try to follow throughout my career is first of all really getting to know the patient,” says Robert Juhasz, D.O., an internist affiliated with the Cleveland Clinic and former president of the American Osteopathic Association. “That’s why I focus on getting a good history when I meet a patient for the first time, so I can understand what’s going on with them.”
That understanding, he adds, also enables him to grasp the external obstacles the patient faces in improving their health. “You can say you’d like to see them move towards a healthier diet, but if you think they don’t have access to nutritional food, you have to ask, ‘Is that [goal] something you think you could do? If not, what would get in the way?’”
Juhasz says he lets patients set the agenda for the visit in terms of what they see as its purpose and their expectations for it. Doing so, he says, provides important insights into the patient’s daily life, such as whether and how much they smoke or drink, if they are sexually active, the type of work they do and whether it exposes them to health risks.
“You may not be able to do all of this (what the patient wants) because we’re all time pressured these days, but it’s important to do as much as possible,” he adds. “Because if you don’t, you could miss the opportunity to know what motivates the patient to actually make changes in their life.”
Building such relationships may not be easy during a brief appointment, but it is possible, says Gersch.
“If a patient is coming in for a 20-minute medication follow-up or their yearly physical, you can still build that trusting relationship, but it’s not going to happen over one or two visits,” he says. “It’s going to take a period of years before that patient feels comfortable enough to tell you they’ve only been taking a prescription medication once a day instead of three times because they can’t afford it.
“The ‘art’ aspect of medicine is a lot easier when you have that long-term relationship,” he adds.
The ability to “read” a patient and know what style of doctoring they best respond to is also part of the art of medicine, says Arnold.
“I think to be successful at patient (adherence) requires the skill set to act paternally with some patients, meaning you make the decisions for them, and other times to be more fraternal and make the decisions together,” he says. “The doctors who are good at patient care are able to flip those roles depending on what works best for each patient.”
What motivates the patient?
Another advantage that comes from developing long-term relationships with patients, Arnold says, is uncovering what they value and enjoy in life — key to developing a treatment plan the patient will stick with for the long term. He cites the example of one of his patients whose love of reading motivates them to keep their diabetes under control.
“They don’t want to run marathons or lose weight, but to lose their vision due to the macular retinopathy that often comes with diabetes would be devastating,” he says.
Although not a primary care doctor, plastic surgeon and Physicians Foundation President Gary Price, M.D., confronts many of the same difficulties when it comes to changing patients’ behavior. But for Price, the task is persuading sun-worshiping patients with skin cancer to reduce their exposure to solar radiation. “Convincing them to do that can be a real challenge,” Price admits.
Like Arnold, Price tries to learn as much as he can about a patient to find what is important to them and use that information as a motivational tool. “When I ask many of my older patients, the answer often is something like seeing a grandchild graduate or the desire to remain physically active,” Price explains, “Once you understand what motivates them, the reasons for avoiding heavy sun exposure can be put in that context.”
Sticking with the plan
Uncovering the patient’s goals is just the beginning, Price adds. After that, it is critical to regularly remind them of what they need to do. “One can talk about the importance of applying sunscreen, but the big challenge is getting them to put it on when they get up every day. And if they continue experiencing heavy sun exposure, the challenge is getting them to mitigate its effects.”
Gersch says a technique he has found often works for patients in effecting a major lifestyle or diet change is to break it into what he calls “doable portions.”
“If a patient needs to lose a lot of weight, instead of coming right at them I might start with, ‘Let’s see if we can get to where you’re not gaining weight anymore. Then let’s see if we can get to where you’re losing a few pounds.’ That way it doesn’t seem overwhelming, but it becomes more like, ‘Yeah, I can give that a try.’ I’ve found that’s a lot more effective than just telling them they need to lose 150 pounds,” he says.
Like many other physicians helping patients cope with adherence challenges, Gersch finds it is crucial to enlist the help of family members, especially spouses.
“That’s usually the person the patient is spending the most time with,” he says. “So, if the patient needs to quit smoking or cut back on alcohol or whatever, if you can get the spouse’s support, and maybe even say they’re going to do it as well, that makes it much easier for the patient.”
Conversely, lack of support can make the desired behavior change more difficult, if not impossible, says Gersch. “If the husband’s dealing with a heart issue and the wife does all the cooking, if I can’t get her on board for making heart-healthy meals, it’s not going to happen,” he says.
It takes a team
A further important contributor to successful adherence, doctors say, is team-based care. “Designating roles for members of the health care team to assist in additional counseling or follow-up to check in on patients can help to make sure they are continuing their treatment plans,” Mire says. He adds that a team member who can spend time counseling patients also provides an opportunity to identify any social or cost barriers to adherence patients may be facing.
“Having motivated team members who care about patients is a fundamental part of managing chronic disease,” says Arnold, adding that some of his long-term patients have become friends with the nurses in his practice. “When they come in it’s more like a social visit and I’m kind of an afterthought,” he laughs.
Meeting the cost challenge
Inability to afford prescription medications poses another adherence barrier and one doctors say they are seeing among more of their patients. Not only are the prices of many medications rising, but patients are paying more out of pocket for them. A 2020 IQVIA Institute study found that patient out-of-pocket costs for prescription medications jumped by 8.1% between 2015 and 2019, from $74 billion to $82 billion. And although 9% of all prescriptions in 2019 went unfilled, the rate was 45% for those with an out-of-pocket cost of $125 or more.
The problem is exacerbated by some patients’ unwillingness to admit they cannot afford their medications. “They feel like they’re saying, ‘I’m not successful enough in life to afford these prescriptions,’ and it’s embarrassing for them to admit that,” Arnold says.
“I think physicians today are much more conscious of cost than when I started practice,” he adds. “Back then I didn’t know what one blood pressure medicine cost compared to another, but now I’m very sensitive to it.” When the problem arises, he assigns a nurse to call local pharmacies or use an app to compare prices for the patient.
Gersch says the affordability problem often takes the form of underinsurance. “They have insurance, but it comes with a deductible that’s higher than they can afford out of pocket. We’re seeing that quite a bit,” he says.
In such cases, he and his staff look for workarounds, such as asking the drug manufacturer whether it has assistance programs for which the patient qualifies. Sometimes he will give the patient samples, but only as a last resort. “I’d rather have them on a medicine they can afford and use long term,” he says.
But despite help with prescription costs and the myriad other types of adherence support physicians offer, some patients are unwilling or unable to follow a treatment plan. When that happens, it is important not to get discouraged, says Juhasz.
“Most of us really care about our patients, and when they have a bad outcome it bothers us,” he says. “But you have to understand some patients are not going to change, but that doesn’t mean you quit. You have to meet them where they are and offer what you can.”