PMID: 11154171

Issn Print: 0192-0790

Publication Date: 2001/01/01


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Compliance, Adherence, and Hope

Howard Spiro

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Nigro et al. 1 in this issue of the Journal make the point that compliance (taking medications as ordered) with medications is important in the management of gastrointestinal disorders, a comment with which no gastroenterologist could disagree. Following doctor's orders, as they used to be called, is not as bad for the patient as current opinion, currently antiparentalistic, opines. Indeed, students of placebos know that patients who take placebos faithfully are likely to do better—to have fewer complaints—than those who are not so faithful to their instructions. Doing what the doctor advises, of course, may be simply a marker of good health behavior in general, or just an effect of positive emotions. I lump that response under “hope,” which, in more than a few quarters, is deemed to be important in recovery from many human travails. The power of the placebo may also be telling us something about a quasi-liturgical need for order and for regularity in the human body. After all, few gastroenterologists must ever have doubted the spiritual benefit of regular bowel evacuations, which bring contentment if not always good health.
Such considerations are pertinent to the conclusions of Nigro et al. 1 that patients with inflammatory bowel disease (IBD) who have emotional problems are poorly compliant in taking medications. The authors may go too far in suggesting that “IBD makes the patients crazy” inasmuch as no psychiatric diagnosis had been made, or even considered, before the onset of IBD. That, of course, is not quite the same as claiming that no psychiatric diagnosis existed.
Compliance itself is a word whose time has come and gone, for it has long been replaced, in the psychosomatic trade, by “adherence”. Compliance implies following orders or suggestions, whereas adherence gives the impression that the patient, who may be following the doctor's orders, has decided to do so out of free will. That same change in emphasis accounts for the new emphasis on “informed decision making” instead of “informed consent.” They mean the same thing, but they give voice to different viewpoints.
That adherence goes up the longer the patient is sick, in this study at least, could mean that patients who have not taken their medication learn to become more faithful when they feel no better or suffer recurrent flare-ups that respond to medication the doctor ordered. On the face of it, that makes sense, but we are not given the details of any psychiatric evaluation and I remain skeptical that American patients place that much faith in physicians who do not seem to be helping them very much.
Nevertheless, studies like this are to be commended, for they help gastroenterologists to accept the very old idea that body, mind, and—yes—spirit are all needed in the management of most gastrointestinal problems, particularly those like IBD. Firm in that belief, in the days when hospitals were places of refuge and not profit centers, I had a psychiatric social worker, Ms. Gail Goldman (latterly Korrick) working in our private gastrointestinal clinic at Yale for about 20 years. I believed then—and I believe now—that either IBD brings troubles with it or that other stresses make the symptoms of patients with IBD worse. In any event, Goldman-Korrick, was extremely helpful to the people who came to our clinic. I have the feeling, quite often indeed in our ambulatory clientele, that emotional support is sometimes as important as the prednisone or any other mixtures we gave, or the ones we give now.
The lesson I take from these observations in Italy is simple.
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