Conscientious Objectors : What to Do When Doctors’ Advice and Prescriptions Are Hard to Swallow

A SANTA MONICA pediatrician became frustrated when a 9-year-old boy was brought to her office for the third time in less than a month. The boy, who had severe breathing problems, was supposed to be taking a powerful anti-asthma medicine that was critical for his health. But it was obvious that he had not, and his symptoms had steadily worsened. Now, concerned that the boy’s mother did not understand the seriousness of the illness, the doctor sat her down, yet again, to explain the dangers of asthma. And the mother, who was equally frustrated, insisted that she had tried to give her son the pills, but the medicine upset his stomach and he refused to take it.

Like the child’s mother, many people do not follow doctors’ orders, often for good reasons. Studies show, for example, that at least a third of patients fail to take medicines as instructed. They stop the prescription before it is completed, take the wrong dose, or forgo the medicine altogether. According to one study, people with strep throat who are given a seven-day course of antibiotics commonly stop taking the medicine by the third day. Another study found that only two-thirds of patients being treated for high blood pressure actually take enough medicine to control it.

Doctors refer to patients who follow a medical regimen as “compliant.” Those who fail to do as they are told are labeled “noncompliant.” The labeling implies that a person who does not take medication as ordered is behaving in a deviant way. But in fact, about half of all people being treated for such chronic medical conditions as high blood pressure, diabetes, arthritis and depression fall into the noncompliant category. Noncompliance, according to one group of researchers writing in the Annals of Internal Medicine, may be the most significant problem facing doctors today.

But the notion that a patient always ought to do as told suggests that the physician alone knows what is best and the patient knows nothing. That, of course, is false. People have a variety of reasons for not taking medicines as prescribed. Studies show that an individual’s social class and level of education have no bearing on whether that person takes a medicine, but the medicine itself does make a difference. People are less apt to take a medicine if there are troublesome side effects, if it has to be taken for a prolonged period, or if there are complex instructions for taking it.

In some cases, the high cost of drugs is the overriding factor. A 70-year-old woman with a skin infection who received a prescription for antibiotics recently was shocked to learn that the drug would cost $58. She simply could not afford the drug, so she had no choice but to treat her infection with home remedies. Had her doctor understood her financial constraints, he could have prescribed an equally effective drug at half the cost. But most doctors do not consider the price of a drug when prescribing. In fact, most do not even know the prices of drugs. Consumers learn the prices when they go to pay for them, because insurance plans often do not cover prescription drugs.

At times, the failure to follow medical advice can be extremely dangerous. In the case of the boy with asthma, his recurrent breathing problems could have fatal consequences. The physician knew that, and focused her efforts on repeating the instructions for the medicine ever more carefully and slowly. But this was little help to a mother who needed to know what to do when her child became nauseated. Should she lower the dose? Was there a different form of the medication that might not have that side effect? Was she giving the medicine too close to mealtime?

When patients do not ask specific questions, doctors may fail to address the problems of medications. Hospitals require that doctors recommending a surgical procedure list all the possible adverse consequences of the surgery, and patients are even asked to sign a form saying that they understand the reasons for the surgery and the possible risks. But there are no such built-in mechanisms for explaining the benefits and risks of prescriptions.

Because the misunderstandings about medicines are so common, anyone receiving a new prescription should ask the doctor a few key questions:

--Why is this medicine important?

--What will happen if I don’t take it?

--What side effects should I expect?

--Is there an alternative medicine that is cheaper or causes fewer side effects?

Even when all the questions have been answered, it is difficult to take medicines on a regular basis. Realizing this, medical technology and pharmaceutical firms have developed a variety of shortcuts--ways to ensure that people receive the maximum benefit of a medicine for a minimum of effort. For example, women with uncomplicated bladder infections who would have been prescribed a 10-day course of antibiotics just a few years ago may now be treated in the office with a single super-strong dose of medication.

Similarly, people with certain venereal diseases may be treated with a one-time injection.

Despite these, people with chronic illnesses may simply decide on their own when to take a medicine, regardless of their doctors’ advice. Medical sociologist Peter Conrad and his colleagues at Brandeis University in Boston interviewed people with epilepsy who are obliged to take medication daily to control seizures. More than 40% of those interviewed said they frequently modified their prescription without consulting a doctor, generally by stopping the medicine for a period of time or lowering the dose.

They especially did this when the medication seemed to be ineffective, or when the side effects became too disturbing. The researchers suggested that doctors stop asking why people don’t “comply” with their orders and instead start trying to understand the need for individuals with a chronic illness to assert some personal control over that illness through their medications.