What gets us into trouble
is not what we don't know
It's what we know for sure
that just ain't so
This is the 1st in a series of posts on widely held and pernicious health myths.
There's a lot of talk about improving quality in healthcare. Compared to other industries healthcare lags far behind in adopting the concepts and applying the tools of the quality movement. There is a lot that can be applied, and not just for improving the quality of systems but also for dealing with people.
One of those people-issues is adherence. The problem of poor adherence—the inability of patients to follow their medication regimens accurately and consistently—is widespread and well known. The likely benefits of improved adherence are also well accepted: "Effective ways to help people follow medical treatment would have far larger effects than any treatment itself" (Lancet, 1996).
Given its importance, many studies have been conducted to understand the problem and numerous efforts have been made to solve it. A wonderful overview of medical studies on this topic is Adherence to Medication by Lars Osterberg and Terrence Blaschke. And, many efforts have been made to increase adherence, including more education, easier regimens (e.g. 1 pill a day, rather than 2 or 3), and financial rewards and threats. Nothing seems to make much of a difference.
At first glance, it seems absurd that adherence is so poor. After all, how hard can it really be to take a pill on a regular schedule? Even self-injections (such as for diabetics), though unpleasant, are not especially difficult.
This has led to the myth: people don't adhere because they don't want to; people don't care about their health.
The Red Bead Experiment
Dr. Edward Deming, one of the founders of the quality improvement, used the "Red Bead Experiment" to teach a key point about quality. This experiment is really a performance piece, a skit.
The cast: three workers, a foreman, and a quality inspector
The situation: a bin is filled with beads, of which 80% of are black and 20% are red. The workers use a special paddle to collect beads from the bin, and place these beads in a second bin. The quality of the workers' performance is judged by the percentage of black beads versus red beads in the second bin. A higher percentage being better quality.
The action: foreman tells workers what is expected. Workers transfer one paddle of beads. Quality inspector determines that the second bin has roughly 80% black beads. Foreman fumes and exhorts workers to do better. Workers do their job again, quality inspector checks again, and again the result is about 80%. Foreman is livid, yells at, threatens, demands better performance. Workers try again, quality inspector checks again, 80% again.
The lesson: the workers are limited by the tools at their disposal. There is simply no way to get a higher percentage of black beads out of the first bin with the given paddle. The problem is not one of worker competence or motivation, but of capability. In this case, as in many others, capability must be improved through better tools and processes.
The situation with adherence is much the same. The problem is not simply one of poor knowledge or desire—even smart, motivated people have poor adherence. It is in fact a problem of capability.
It is true that each particular activity in a health regimen—taking a pill; checking and recording weight; recording lunch in a food journal; noting an event of pain or nausea—is relatively easy to do. But, if you have 20, 30, 40 or more such activities spread throughout each day, as is common for people with chronic illnesses, it is difficult to do them properly and consistently every day, forever. If you also have a normal, busy life, with the activities and responsibilities of family, work and society, it is in fact extremely difficult. This is why adherence is so poor! It's almost impossible to be properly adherent. At least without better tools.
Quite simply, people need help remembering all of their scheduled health activities and need an easier way to keep track of all them. People need tools or services to make remembering and recording much, much easier than it is today.
To significantly improve adherence, we must discard the myth of irresponsible patients, and take on the challenge of developing tools that help people. We've got to give those workers better paddles if we want fewer red beads.