Strategies for improving patient concordance

Dr Prashini Naidoo explains the difference between patient compliance and concordance.

Compliance and adherence refer to patients following the advice of healthcare professionals, while concordance is a concept that describes specific interaction and co-operation between patients and healthcare professionals, which addresses patients' needs.

Sometimes it is easier to understand the concept in the negative: non-concordance is the failure of both parties to come to an understanding, rather than a failure of the patient to understand.

I recently watched a series about Gordon Ramsay's food quest through India and found his episode of imposed vegetarianism in an ashram funny. Gordon complied with a vegetarian diet for one day and adhered to the ashram's rules while on the premises.

His view on meat and health was a million miles away from the guru's philosophy on vegetarianism. While there was some interaction to learn about making vegetables taste better and co-operation to learn about food preparation techniques, Gordon left the ashram with his views intact. He promptly went in search of a beef chilli washed down by a strong coconut homebrew.

So, was Gordon compliant with or adherent to the guru's teachings? Did he and the guru achieve concordance?

Concordance is important

GPs work in partnership with patients to improve their health. If patients develop a better understanding of their disease, health and treatment options, both doctors and patients are more likely to be satisfied with the giving and receiving of care, and more likely to achieve better health outcomes.

If Gordon had hypertension, his GP might talk to him about lifestyle changes and medication, for which there is an evidence base. In this way, the GP is placing value in evidence-based medicine.

Gordon's guru might talk to him about cutting out meat. The guru is placing value in religious practice.

Gordon may want to ignore them both, partly because he can, placing value on his autonomy, and partly because he really enjoys meat, placing value on his hedonism.

The ideas and philosophies that drive our decision-making are divergent and unlikely to be completely reconciled. However, sometimes if we are working towards the same goals (better health), we make truces and compromises to form effective alliances; we work in concordance.

Obstacles to concordance

If we conceptualise concordance as forming effective alliances, factors that could sever an alliance would be distrust in the partnership, poor communication, poor information sharing and failure to agree a plan.

If Gordon wants to work with his GP to lower his BP by addressing his lifestyle, he may be willing to trust someone who is adaptable and respectful of his beliefs, who, while not agreeing with all of his beliefs, nevertheless conveys an understanding of his feelings and gives personalised information. At the end of a discussion with Gordon, a holistic GP would know:

  • Does Gordon think hypertension is a serious condition?
  • How susceptible does he feel to MI, stroke, or heart failure?
  • What benefit does he see in changing his lifestyle or taking medication?
  • What is going to hinder him in making lifestyle changes?

Skills for concordance

The effective GP communicates well. Non-verbal communication is important. By this, I refer to attentive, focused listening, good eye contact, listening to how people say things, and attending to their ideas, discourse and feelings.

Successful GPs respond empathically and can summarise back to the patient how the patient perceives their problem and health beliefs.

GPs working in partnership with their patients can distinguish between patients' needs and wants, and can identify the gaps between what the patient knows and needs to know. Therefore, the content and style of the GP's communication is tailored to the individual patient.

Some patients want to play a bigger part in decision-making than others, so it is important to elicit the patient's preference for participation.

Patient-centred GPs also check regularly with patients about how they would like to proceed. Having elicited the patient's values and beliefs, the effective GP discusses options, personalising those that are compatible with their lifestyle, and ensuring the risk and benefits are understood. The patient's choices should be respected.

If someone asked Gordon how his GP helped him to set his goals and supported him through making his lifestyle changes, the GP should ideally be portrayed as a facilitative, encouraging and knowledgeable person, who understood him as well as his illness.

Communication techniques

I recently undertook some training in CBT, especially 'guided discovery'. I learnt that it is important to ask patients about the cognitions (automatic thoughts, images or beliefs) they hold about their problem.

CBT asks patients if they can see their cognitions as ideas, rather than truths. To prompt patients to critically explore their thoughts, it is sometimes helpful to ask one or more of the following questions in an interested, non-judgmental way.

Let us assume Gordon thinks: 'I already eat a healthy diet and exercise enough; I don't have to change anything about my lifestyle.' But we would then ask:

  • Gordon, what evidence do you have that supports this idea?
  • What is the evidence against this idea?
  • Is there an alternative explanation or viewpoint?
  • If I believed this idea, what is the worst that could happen? If it happened, how could I cope? What is the best that could happen? What is the most realistic outcome?
  • What is the effect of believing my idea? What could be the effect of changing my thinking?
  • What would I tell a friend if they were in the same situation?
  • What should I do now?

GPs talk about planting an idea or seeding a change. The above questions, asked and discussed in a safe setting, will allow patients to reflect on their views. Some patients (and GPs) may actually shift their views after their reflections.

  •  Dr Naidoo is a GP trainer in Oxford

Resources

  • Glanz K, Marcus Lewis F, Rimer BK. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, National Institute of Health, 1997.
  • Beck JS. Cognitive Behaviour Therapy: Basics and Beyond (second edition). New York, Guilford, 2011.

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