Letters

"Medication concordance" is best helped by improving consultation skills

EDITOR"Medication concordance" is a term used to signify that the doctor and patient have come to a shared agreement about therapeutic goals.¹ It is merely one end point; to have reached it the doctor would have had to develop a rapport with the patient, understood the illness in his or her terms, come to a shared understanding and agreement about the diagnosis, and imparted information about the proposed treatment and given alternative choices. The doctor should provide the patient with alternative professionals for independent advice and allow time for the patient to decide on his or her future management. Medication concordance may require a radical change in consulting styles and a deeper understanding of patients' health beliefs. The term refers more to a metamorphosis within the profession than to us enforcing our agenda on the patient.

Collier and Hilton have suggested that the patient should enter into an agreement about the proposed treatment by signing his or her own prescription.² This distracts from the main task of improving doctor-patient communication. The power that the doctor has within the doctor-patient relationship cannot be underestimated; most patients would find it difficult to refuse to sign a prescription, whether during the consultation or afterwards. This is borne out by the fact that many prescriptions are cashed without the drugs being taken.³ Having to sign a prescription may make it even harder for patients to come back and tell the doctor that they broke the contract by failing to take the drug.

Once a prescription is issued, particularly for chronic illnesses, the process of fine tuning is important. Patients fail to take drugs for various reasons, some commonly known (for example, unwanted side effects) and others more pertinent to individual patients. Clinical pharmacists are sometimes used in general practice surgeries as medication counsellors.⁴ In a recent study I audiotaped 25 consultations and analysed them using qualitative methods. Patients tended consciously to modify their drugs rather than simply forget. Factors leading to non-adherence included patients' perceptions about the potency of their drugs, inadvertent overuse and potential poisoning, culturally led ideas about the use of drugs long term, and drugs with a reputation (such as antidepressants and their reputation for being addictive).

Patients signing a prescription would contribute little to improving medication concordance. Instead, more will be achieved by further improving consultation and communication skills as an integral part of doctors' training, disseminating more evidence from qualitative studies on patients' health beliefs, and carrying out more research on the potential use of medication counsellors.

Judy Chen, General practitioner. 
Rushey Green Group Practice, London SE13 6LL drjudychen{at}email.msn.com

1. Blenkinsopp A, Bond C, Britten N, Feely M, George C, Green P, et al. From compliance to concordance. Achieving shared goals in medicine taking. A working party report. London: Royal Pharmaceutical Society of Great Britain and Merck Sharp and Dohme , 1997.
2. Collier J, Hilton S. Doctors and patients should sign prescriptions. BMJ 1998; 317: 951[Free Full Text]. (3 October.)
3. Dunnell K, Cartwright A. Medicine takers, prescribers and hoarders. London: Routledge and Kegan Paul , 1972.
4. Chen J. The pharmacist in primary care in an extended role as a medication counsellor: an exploratory study into future possibilities [MSc dissertation]. In: London: University of London , 1997.