Health: Second Opinion

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ONE of the reasons sick people get better once admitted to hospital is that there they are much more likely to take the treatment that has been prescribed for them. Research has consistently shown that at least 30 per cent of patients taking medicine at home do not follow the instructions on the bottles and that many do not take their medicine at all. Yet when treatment seems to fail, doctors often assume that the explanation is drug resistance or wrong choice of drug.

Recently, for example, reports have suggested that tuberculosis is becoming resistant to 'all known drugs'. In reality, treatment of this illness - which nowadays largely affects the homeless and people with drug and alcohol problems - is still highly likely to work when given under supervision. That means having each dose of antibiotics administered by a health worker who watches that the tablets are swallowed.

Non-compliance, the technical term for not taking the tablets, is also found in short- term illnesses such as tonsilitis in children and in long-term disorders such as raised blood pressure. Doctors asked to explain the high rates of non-compliance often say patients do not value treatments they get for nothing (many patients who are prescribed NHS drugs are exempt from prescription charges). Psychoanalysts assert that payment by the patient is 'an essential part of the therapeutic relationship', and claims are often made that compliance is better among patients who are treated privately.

But these theories do not explain why non-compliance is so common in all health systems. The main reason patients do not follow the instructions on their medicine bottles is that the doctor has not explained why the medicines need to be taken. Far too often doctors do not even name the drug they are prescribing, let alone say what it is meant to do. They fail to distinguish between a medicine intended to treat the disease and one intended to relieve its symptoms. For example, many children prescribed antibiotics for throat or ear infections stop the treatment once they feel better, increasing the risk that the infection will recur and that the bacteria will become resistant. Yet doctors do not say how soon the patient can expect to feel better - though with some drugs, such as antidepressants, no improvement may be expected for 10 days or longer.

Doctors also omit to say what to do if a dose is forgotten or cannot be taken because of an attack of food poisoning that causes vomiting and diarrhoea. They rarely explain what side-effects may occur, arguing that if the patient is told a drug may cause headaches then he or she is more likely to get one; nor do they say whether the treatment should be stopped if side-effects do occur.

Patients want this information, as is shown by the popularity of books giving basic facts about common drugs. Ideally, it should be written down, but a leaflet is no substitute for person-to-person explanation. Much of the information can be provided by the pharmacist, if he or she is asked, but the responsibility lies with the prescribing doctor. Doctors' claims that they don't have time do not withstand scrutiny: a few extra minutes may prevent the return of a discontented patient with continuing symptoms.