Therapeutic Communication and

Monitoring Therapy
Department of Clinical Pharmacology
Faculty of Medicine, GMU
2016

Patients adherence to
treatment
Studies shown that about 50% of what doctors
prescribe for chronic illness does not get taken
About the same percentage was found for each
indication studied, e.g., hypertension,
glaucoma, hypercholesterolaemia, etc.

Factors affecting
patients adherence to
treatment
Why do I have to
take this drug?

I doubt this
is a good
drug

She is nice,
but her
prescription is
too simple..

..too
expensive, I
cant afford..

Drugs wont
help, this is a
curse

too
complicated.
.

To minimise nonadherence.

Simplify dosage regimen

Involve patients in
therapeutic decision
process

Patients rights
Patients have a right to determine what happens to their
own bodies (WHA 47)
Patients have a right to be given information about
medicines they are prescribed, and patients should have
access to appropriate and understandable information
about medicines and their side effects (WHA 47)
Patients have a right to be fully informed about the
potential benefits and risks of the medicinal products
before they are prescribed (WHO, 1994)
Patients have a right to be fully informed about the
proposed medical procedures, together with the
potential risks and benefits of each procedure, about
alternatives to the proposed procedure, including the
effect of non-treatment (1994).

Your patients are not

illiterate.
Town
Clinics 2%

Drugstore 35%

Hospital 1%

Doctor 7%

MEDICINES
(n=1324)

Neighborhood
Store 40%

80%..!
Neighbors and
Relative 5%

10%..!
Household Stocks
and Free Clinics 8%

Neighborhood
Anita Hardon, 1991

Problems in
communication
Gaps between doctor-patients in social level or
language
Doctor fails in providing enough consultation time
Lack of skills in retrieving information from the patient
Mis-interpretation of information
Patient does not agree with the treatment
Patient forgets the information/instruction
Patient is not capable to do the instruction
Information/instruction is too complicated
Information/instruction is incomplete
Patient has inconvenient experience with the doctor
Etc.

Doctors bias

about the patients

Doctors think that patients have the same
concepts about illness and disease etiology
Doctors think that patients have the same
concepts about cure
Doctors think that patients understand the
doctors language
Doctors think that when patients say yes (or
nod), it means they agreed or understood
Etc..

Different concepts

about illness/disease
etiology

Different people have different concepts

of disease

Bacteri
a,
viruses.
.

Cold,
heat,
wind..

Differe
nt
foods..

Evil eye,
bewitchin
g..

Faith,
immoralit
y..

Different concepts of cure

Destroy bacteria?
Remove symptoms?
Take away visible lesions?
Control measured signs,
e.g., blood pressure?
Etc?

Different concepts

about the value of

medicines

Colors: blue, red, green, yellow?

Forms: tablet, capsule, injection, suppository?
Taste: sweet,
Pain relief score after taking
bitter, sour,
different colors of placebo
2
tasteless?
1.5
Price?
Source?
1
Packaging?
0.5
Provider?
0
0
1
2
3
4
5
6
Etc..?
Time
Huskisson, BMJ 1974

(hours)

Effect of

promotion and
marketing
Direct promotion to consumer of even
prescription drugs is common
Advertisements usually promote
brand names, may be inaccurate or
misleading
Consumers are very sensitive to some
advertising messages

Six steps of

therapeutic decision
(WHO,
process
1994)
Step
Step
Step
Step
Step
Step

1:
2:
3:
4:
5:
6:

Define the patients problem

Specify the treatment objective
Select medicine
Start the treatment
Give information to the patient
Monitor (or stop?) treatment

If you start talking to patients at step 5, it is too

late..!!!!

Discuss with your patients.

Nature of the disease
Treatment objective's
Choice of treatment, including non-drug
treatment
Benefits and risks of treatment, including
those of no-treatment
Dosage regimen
Treatment cost
How, when to monitor the result of
treatment

The minimum information

1.
2.
3.
4.
5.
6.

Effects of the drug

Side effects
Instructions
Warnings
Future consultations
Everything clear?

Unlimited

techniques to involve
patients

1. Share with the patients what is in your mind

(Yati Sunarto, Senior Pediatrician)

2. Ask the patients opinion when you have options

(Inu Wicaksono, Popular Psychiatrist)

3. Make encouraging statements, e.g.,

You are absolutely right, could you tell her not to ..

4. Use open-ended questions to check understanding

Correct: could you tell me how would you take this
suppository?
Incorrect: you know how to take this suppository, dont
you?
Correct: when will you see me again?
Incorrect: come again next week, OK

5. Etc?

Techniques to check
adherence
Counting pills
Monitoring therapeutic effect
Simple technique to monitoring
drug concentration:

Color of urine
Smell of urine

STEP 6:
Monitor (and stop?) the
reatment
Was the treatment effective?
a. Yes, and disease cured
:
b. Yes, but not yet completed:

Stop the treatment

Any serious side effects?

No : treatment can be continued

Yes : reconsider dosage or drug choice
c. No, disease not cured:
Verify all steps:
Diagnosis correct?
Therapeutic objective correct?
P-drug suitable for this patient?
Drug prescribed correctly?
Patient instructed correctly?
Effect monitored correctly?

Type of monitoring
Passive monitoring

monitoring is done by the patient

Active monitoring

Monitoring by physicians

Personal formulary
Tablet 50, 100 mg
Beta blocker
ATENOLOL
* DOSAGE
Hypertension: start with 50 mg in the morning. Average: 50-100 mg per day.
Angina pectoris: 100 mg per day in 1-2 doses
Adjust to each patient individually, start as low as possible. Raise the dose after 2 weeks, if
needed.
* WHAT TO TELL THE PATIENT
Information
Hypertension: drug decreases blood pressure, patient will usually not notice any effect. Drug will
prevent complications of high blood pressure (angina, heart attack, cerebrovascular accident).
Angina pectoris: decreases blood pressure, prevents the heart from working too hard, preventing
chest pain.
Side effects: hardly any, sometimes slight sedation.
Instructions
Take the drug .. times per day, for .. days
Warnings
Angina pectoris: do not suddenly stop taking the drug.
Next appointment
Hypertension: one week.
Angina pectoris: within one month, earlier if attacks occur more frequently, or become more
severe.
* FOLLOW-UP
Hypertension: during first few months pulse and blood pressure should be checked weekly. Try to
decrease dosage after three months. Higher dosages do not increase therapeutic effect, but
may increase side effects. Try to stop treatment from time to time.
Angina pectoris: in case frequency or severity of the attacks increase, more diagnostic tests or
other treatment are needed. Try to stop drug treatment from time to time.