The Arthritis NewsletterSummer 2015
Communicating with your rheumatologist: An argument for adherenceBy Allison Brennan
In which the author makes a case for open communication with medical professionals and adherence to prescribed treatment.
In February I had the privilege of attending the Canadian Rheumatology Association (CRA) Annual Meeting as a person with sixteen years of experience with Juvenile Idiopathic Arthritis. While I anticipated the shock of the frigid winter temperature in Quebec City, I was taken aback by the low medication adherence rates that were reported. Only 30-80% of people with Rheumatoid Arthritis follow the medication regimes prescribed by their rheumatologist (van den Bemt & van Lankveld, 2007). How can adherence be so low? Health professionals have updated their terminology, replacing the authoritative ‘compliance’ with adherence to reflect a shared endorsement of medications by both patients and physicians. Are patients agreeing to medication regimes that they do not actually agree with?
I attended several workshops at CRA that aimed to improve communication between patients and rheumatologists in order to increase medication adherence and improve patient outcomes. During these workshops, rheumatologists learned motivational interviewing techniques from registered psychologist Dr. Michael Vallis of Dalhousie University. Motivational interviewing in this context was used by rheumatologists to assess and engage the wants and needs of patients pertaining to their medications. For example, a rheumatologist counselling a patient with poorly controlled RA about the benefits of adding a new medication would ask the patient questions about their disease activity and their thoughts and feelings about adding a new medication. The rheumatologist would pose these questions with nonjudgmental curiosity and encourage the patient to voice their concerns and resistance to the idea. By respecting any ambivalence or resistance expressed by the patient and having an honest discussion on the subject, the rheumatologist will understand the patient’s wants and needs about the new medication. In doing so, he or she will be able to evaluate whether the patient is likely to adhere to the suggested new medication.
As a patient, I greatly appreciate this approach. I think that this is an excellent technique to improve the patient rheumatologist relationship, medication adherence, and disease outcomes in general. I do however recognize that motivational interviewing is easier said than done, and I think that even the most well-intentioned and skilled rheumatologists could use patients’ help to put this communication training into practice. Communication is a two-way street; thus I encourage patients to hold up our side of the deal.
I employ several strategies to communicate effectively with my rheumatologist. Sometimes this is more successful than others, but such is life. The details accompanying these strategies are idiosyncratic to my own experience, but I hope that sharing them will help to illustrate the communication strategies that I have found useful.
- Have an understanding of your disease status when you visit your rheumatologist. How much pain are you experiencing and where is it located? What activities make this better and worse? How’s your energy level? Nausea? A rash? You know they are going to ask you about this so you should have an answer prepared. By thinking about this and planning what to say before your appointment you can save time on this initial assessment so that you can cover more of what’s important to you during your visit.
- Have an understanding of the general trends in your disease since your last visit. How do you feel today? Last week? Last month? Overall, are you feeling better, worse, or the same since your last visit? Although you may have a lot of pain on a particular day or feel tired one week, remember that this may not describe your health over the past six to 12 months since your last visit. Try to tell your rheumatologist about these general trends instead of about that one time your elbow hurt. I think that you are more likely to walk out of the office with your main concerns addressed if you direct the conversation towards these trends instead of specific instances.
- Don’t be afraid to ask for something that you want. This may seem obvious, but it is something that I struggle with. For example, tell your rheumatologist if you really hate self-injecting and would like to talk about other options. I self-injected for almost a decade, and for me, it really took away from my quality of life. I suffered through it because I assumed that I should be thankful that my arthritis was well controlled. However, last year it was no longer controlled and I ended up on three oral medications instead. This works just as well, and with the added benefit that I no longer have to self-inject. There will not be a solution like this for everything, but I think that even the act of asking lessens the burden. At the very least you will share something that is bothering you and gather information about your options.
- Know your priorities. This will be different for every patient, and a patient’s priorities may differ from a rheumatologist’s priorities. Your priorities may be disease management and raising a family, or you may value drinking alcohol more than disease management, or you may aim above all else to take the least amount of medication possible, or you may be willing to take any amount of medication in order to be able to run while preventing joint damage. I think it’s safe to say that your rheumatologist wants you to have the best health outcome possible. Patients have a responsibility to communicate their priorities to their rheumatologist so that these things can be considered when selecting an appropriate medication regime. I suspect that differing patient and rheumatologist priorities are the root cause of low medication adherence rates; communication is an important step to address the issue.
- Know what you know, know what you don’t know and ask the expert. Patients have lots of experience managing their own disease, but rheumatologists have experience managing the diseases of lots of people in addition to extensive clinical training. As a result, your rheumatologist has lots of data on what factors result in favourable disease outcomes versus poor outcomes. I think it is important to make use of this valuable resource and ask questions. Sometimes I know that I lack information so I ask my rheumatologist about markers of inflammation in my lab work. Sometimes I need a reliable source of information on the latest dietary cure for arthritis and I ask my rheumatologist whether there is any science to back up the claim. Sometimes I’m scared about my future and I ask whether the things that I am doing today like running and drinking alcohol will negatively impact my health in the years to come. I find that open and honest questions lead to answers of a similar character, and overall result in more effective communication with my rheumatologist.
Motivational interviewing videos from Dr. Michael Vallis of Dalhousie University:
Canadian Rheumatology Association website