This is a small book about a big topic. In fact, an argument could be made, that the problem of medication nonadherence is one of the, if not the, major roadblocks to providing effective care in medical practice today. It clearly should be one of the topics most rigorously addressed by all medical, nursing, physician assistant, and clinical pharmacy students during their training. Having intentionally written the book in an informal and conversational style, I hope that these same students will rapidly feel at home with the pages that follow. It is meant to read with the comfortable familiarity of a bedside consult from a colleague one trusts.
It is also my hope that veteran clinicians will feel equally at home perusing the following pages, for their years of clinical experience will provide an entirely different - more powerful lens - with which to play with the following ideas. If I've done my job well, as an experienced clinician reads on, he or she will find interviewing techniques and strategies that validate their current practice, provide a handful of immediately useful ideas for their future practice, and, most importantly, stimulate them to find new answers born from their own clinical wisdom.
The techniques in this book are not provided as the "right way" to increase our patient's interest in their medications, but merely as suggestions of various ways of tackling these difficult and sometimes vexing problems. The reader is invited to check out the following techniques, adopt the ones they like, discard the ones they don't, and create ever more powerful solutions that resonate with their own interviewing styles and the unique needs of their patients.
Before I turn the reader loose to follow up on my invitation, I should mention where the interviewing tips, that dot the pages of this book, have originated.
Over the past six years, as the Director of the Training Institute for Suicide Assessment and Clinical Interviewing (TISA) - - suicideassessment.com - - it has been my privilege to present workshops on medication adherence and other aspects of clinical interviewing to psychiatrists, primary care physicians, nurses, clinical pharmacists, and CHF casemanagers from around the country. At each workshop I ask my workshop participants to stop me if any of the ideas that I suggest seem impractical in a primary care clinic or in a community mental health setting. In the following pages, I share only those ideas that have passed the "acid test" of their discerning judgement.
More importantly, I always invite the participants of my workshops to share the tips that they have found to be most useful in their daily practices their private cache of clinical pearls. This book is a direct result of these workshops. It is a compilation of the practical tips, suggested at my workshops, coupled with the lessons that I've learned in my own clinical practice over the years.
Concerning my personal ideas for improving medication interest, I should state that they originated far from the world of the Ivory Tower. For almost five years I directed a front-line "in the trenches" psychiatric team that focused upon the thorny issues surrounding adherence. This team provided outreach to severely impaired psychotic patients at a community mental health center. Our patients were hidden away in the rural back roads and small towns of southern New Hampshire. These teams, known as Continuous Treatment Teams (sometimes called ACT teams), were designed to provide care for only the most seriously impaired of mental health patients.
By way of example, to be eligible for care under our team, the patient had to have either out-of-control schizophrenia or bipolar disorder. In addition the patient also had to have either active alcohol or street drug abuse. Furthermore, they had to have one or several of the following: multiple suicide attempts, multiple acts of violence, or multiple hospitalizations. Needless to say, as these patients first joined our team, they were not big medication advocates. Indeed, our clinical challenge was, in essence, to win the Super Bowl of nonadherence.
Our efforts were monitored by a research study run by Robert Drake, M.D., one of the most gifted clinicians with whom I have ever had the pleasure to be associated, and sponsored by the Robert Wood Johnson Foundation. At the end of four years their monitoring efforts revealed that we were able to decrease the number of hospital days per year of these patients, when compared to other more traditional case-management teams, by twenty days per year. In addition, during this time, there were no suicides with this highly vulnerable group of patients.
Much of our success seemed to be secondary to the strikingly high medication adherence that we were able to achieve with many of our patients. And, I am convinced, that it was these same patients that taught us how to do it. We asked and subsequently explored with each of our patients, how we could increase their interest in taking psychotropic agents such as antipsychotics meds that, I might add, can have some nasty side-effects. The answers that they gave, one way or the other, always seemed to return to the complexities and elusive exchanges of the physician/patient relationship. The answers had to do with how we saw them, how they saw us, and how we, together, saw our alliance against their disease. It is their answers equally true for a person suffering from diabetes as for a person suffering from schizophrenia - that provide much of the practical wisdom that follows in this book.
Finally, I should add that for over twenty years, it has been my great pleasure to study and write about the art of interviewing. I have specialized in developing methods for training both inexperienced and experienced clinicians.
Over these years I have become convinced of the necessity of providing the clinician, not only with sound principles, but with direct examples of how to implement these principles. The clinician needs to see the exact phrases and questions that can transform a sound principle into a sound practice. In the last analysis, mastering interviewing is probably not as dependent upon knowing what to say than upon knowing how, and when, to say it. Thus, as was the case with my previous books, I have tried to pack this primer with sample questions and concrete interviewing strategies.
In closing, I hope the reader enjoys the following pages. I certainly enjoyed writing them. I truly believe that, in the last analysis, it is a privilege to be a physician, a nurse, a physician assistant, a clinical pharmacist, or a case manager.
Our journey, as physicians and healers, is a rich one. In our efforts to provide help to our patients we sometimes succeed and we sometimes fail, but we always learn. As we move more deeply into their pains and their fears, we encounter the reflections of those pains and fears - their hopes and expectations. Our medications become their hope for relief and their expectations are that our medications will provide it. Sometimes they do, sometimes they don't.
It is here - within the chaotic world where suffering and compassion meet and sometimes collide - that we move ever more deeply into the souls of our patients. Once there we have the great privilege, as Albert Schweitzer observed, to suddenly know what it is "to become true human beings." These moments are the moments that define our livelihoods as physicians, nurses, physician assistants, clinical pharmacists, and case managers. This book is about such moments.