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Judging Drugs: Patients' Conceptions of Therapeutic Efficacy in the Treatment of Arthritis
Implicit images of human behaviour influence most research endeavours. Studies of patients' “compliance” with doctors' instructions have generally used an ideal image of the patient as a passive, obedient and unquestioning recipient of medical instructions. Divergence from this ideal—“defaulting”—is seen as irrational in the light of medical rationality. The blame for “default” is seen as lying with the patient. The research problem is then to find out what there is about the patient that makes him a defaulter. This is a view of the problem from the point of view of the medical profession. An alternative approach from the perspective of the patient is suggested. The focus is then on the social context in which illnesses are lived and treatments used. A more active view patients is entailed in which patients have expectations of the doctor, evaluate the doctor's actions, and are able to make their own treatment decisions. Rather than “defaulting” being found in certain types of individuals, almost anyone can be a “defaulter” at some time or another.
A study was made of 82 patients with selected illnesses of specified severity before and after discharge from the ward services of three general hospitals in a metropolitan community. An initial appraisal was made by a resident physician who evaluated the health status of each patient and made recommendations for care and supervision following discharge from hospital. After an average period of 3 months, each patient was visited by a student of social work who reconstructed the course of events following discharge and determined the extent to which the physicians' recommendations were complied with and the reasons for non-compliance. The usual consequences of chronic illness—persistent disability, unemployment and recurrent and lengthy institutionalization—were amply evident in this group. So was the fact that the burden of continued care falls heavily upon the members of the family. Other sources of help were trivial by comparison. The recommendations made by the discharging physician constitute an interesting, and sobering, inventory of continued need for care. More than a half of all patients did not comply with one or more recommendations made by the physician. In addition, about 40 per cent of patients reported unmet need for one or more services touching upon many aspects of medical care. A variety of lessons relevant to the organized provision of care may be drawn from a consideration of the services needed and desired by patients and of the reasons for, and factors related to, non-compliance with medical recommendations.
A theoretical model, grounded in the experience of about 200 San Francisco Bay area Chicano p patients, of patient non-compliance as a means of asserting control in a patient-practitioner relationship in order to obtain satisfaction with the treatment is presented. The need to modify the treatment arises when it appears to the patient that the original treatment is not totally appropriate. The patient may rely upon convincing tactics (the demand, the disclosure, the suggestion and the leading question) to bring her concern to the practitioner's attention in order that he might modify the treatment. The patient may also take matters into her own hands and use countering tactics to modify the treatment herself. These may be of the augmentation type (simple and additive) or of the diminishment type (simple and subtractive). Convincing and countering tactics may be used sequentially or simultaneously. When a practitioner is aware of her modification attempts, he may be perceived to resort to counter-management tactics to neutralize her own actions. These tactics may be the overwhelming knowledge, the medical threat, the direct disclosure and the personal friend. Bargaining occurs, either unilaterally or bilaterally, during which each party tries for a settlement in which the treatment action of one is at least honored, if not adopted outright, by the other. If the bargaining ends to the satisfaction of both, a desire to maintain the relationship develops. If either or both parties are dissatisfied with the result of the bargaining, the relationship becomes strained and termination becomes likely.
Mothers' adherence to medical instructions concerning their children is typically very inadequate, especially for episodes of acute illness. This study tests a new, behavioral model which employs mothers' health motivations, perceptions, and attitudes as predictors of giving oral penicillin and keeping follow-up appointments for otitis media. Variables in each model category were found to have useful explanatory and predictive value. The findings offer clues to identification of potential noncompliers and suggest particular psychological attributes of the mother which the pediatrician can influence to increase the likelihood of compliance.
Belief and attitude data on certain variables comparable to variables used in other studies of preventive health behavior were collected from a random sample of factory employees in 1958 and used to make predictions as to whether these employees would make preventive or symptomatic dental visits over the next three years. The current study examines the adequacy of these variables for predictive purposes, and suggests the revelance of other variables for prediction. It is found that the best single predictor of behavior is prior behavior. The status of the variables which led to these two studies is examined and their strengths and weaknesses noted.