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“Compliance” to “Concordance”: A Critical View

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Abstract

Advocates of “concordance” describe it as a new model of shared decision-making between physicians and patients based on a partnership of equals. “Concordance” is meant to make obsolete the notion of “compliance,” in which patients are seen as, ideally, following doctors’ orders. This essay offers a critical view of concordance, arguing that the literature itself on concordance, including materials at the web site of Medicines Partnership, the implementation arm in Great Britain of the concordance model, is full of contradiction; concordance, in fact, harbors an ideology of compliance. The essay suggests that an improvement in patient medication use will more likely come from a frank consideration of the relation of compliance issues and commercial ones, and that a key question across domains is, “how are patients/health agents/consumers persuaded to acquire certain drugs and take them as directed?”

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Notes

  1. Working Party, From Compliance to Concordance: Achieving Shared Goals in Medicine-Taking. All subsequent references to this work appear in the text.

  2. Marinker, “Personal Paper: Writing Prescriptions is Easy.” All subsequent references to this work appear in the text.

  3. See, for example, Bissell, May and Noyce, “From Compliance to Concordance: Barriers to Accomplishing a Ref-Framed Model of Health Care Interactions.”

  4. See Habiba, “Examining Consent withing the Patient–Doctor Relationship.”

  5. Stevenson and Scambler, “The Relationship Between Medicine and the Public,” 5.

  6. See Critser, Generation Rx.

  7. Haynes, Taylor and Sackett, Compliance in Health Care.

  8. Haynes, “Improving Patient Adherence,” 5.

  9. Rodin and Janis, “The Social Influence of Physicians and Other Health Care Practitioners as Agents of Change,” 33.

  10. Donovan, “Patient Decision Making.”

  11. Defino, “Getting the Straight A Patient.” Questions of compliance, trust and physician expertise are also discussed in Chapter 7 of Segal, Health and the Rhetoric of Medicine.

  12. See Greene, “Therapeutic Infidelities.”

  13. See, for example, Bonaccorso and Sturchio, “For and Against: Direct to Consumer Advertising is Medicalising Normal Human Experience.”

  14. In “When is a Shared Decision not (Quite) a Shared Decision?,” Gywn and Elwyn say that in the absence of equipoise—a situation “in which options really are options”—decisions are not really shared at all; rather, physicians attempt to induce patients to arrive at decisions “commensurable with their own [the patients’ own] best interests” (446).

  15. Mullen, “Compliance Becomes Concordance: Making a Change in Terminology,” 691.

  16. Milburn and Cochrane, “Treating the Patient as a Decision Maker is not Always Appropriate,” 1906. Marinker’s reply is in “Concordance is Not All,” 151.

  17. Dickinson, Wilkie and Harris, “Taking Medicine: Concordance is not Compliance,” 787.

  18. Marinker and Shaw, “Not to be taken as directed.”

  19. Weiss and Britten, “What is Concordance?”

  20. Marinker and Shaw, 349.

  21. Heath, “A Wolf in Sheep’s Clothing: A Critical Look at the Ethics of Drug Taking,” 857. All subsequent references to this work appear in the text. Marinker responds to Heath in “Coercion, Compliance and Concordance,” 858.

  22. Marinker, “Coercion, Compliance and Concordance,” 858.

  23. “Prescription” itself combines the meanings of “an instruction written by a medical practitioners that authorizes a patient to be issued with a medicine or treatment” and “an authoritative recommendation or ruling” (Concise Oxford Dictionary 1999, 1130–1131). Perhaps, the term that needs examination in medication discourse is not so much “compliance” as “prescription” itself with its sense of ordinance, law, commandment.

  24. Dickinson, Wilkie and Harris, 787.

  25. Elwyn, Edwards and Britten, “ ‘Doing Prescribing’: How Doctors can be More Effective,” 864.

  26. Ferner, “Is Concordance the Primrose Path to Health?,” 821.

  27. Weiss, “Taming the Difficult Patient,” 100.

  28. Ibid.

  29. Ibid, 101.

  30. See, for example, Starcevic and Lipsitt’s Hypocohondriasis: Modern Perspectives on an Ancient Malady. On malingering, see Rogers’ Clinical Assessment of Malingering and Deception. On fibromyalgia, see Groopman’s “Hurting all over”; on myalgic encophalomyelitis, see Horton-Salway, “Bio-psycho-social Reasoning in GPs’ Case Narratives: The Discursive Construction of ME Patients’ Identities; and on whiplash, see Malleson, Whiplash and Other Useful Illnesses.

  31. Edmeads, “Narcotic Alternatives in Acute Migraine.”

  32. Edmeads, “The Dark Side of Medication Abuse.”

  33. Craig and Hill, “Misrepresentation of Pain and Facial Expression.”

  34. Ferner, 821.

  35. Ibid.

  36. All advertiesements noted appeared in popular magazines in the summer of 2004. Effexor promises the feeling of “back to me”; Paxil addresses those who “drop out of school...refuse to date”; Vioxx returns users to a life of “everyday victories”; Cialis helps a couple turn “a silly moment...into the right moment.” Ads and sources are available on request.

  37. Mintzes.

  38. Bonaccorso and Sturchio.

  39. Mintzes, Barer, Kravitz et al., “How Does Direct-to-Consumer Advertising Affect Prescribing?”

  40. Kravitz et al., “Influence of Patients’ Requests for Direct-to-Consumer Advertised Antidepressants.”

  41. “FDA oversight of direct-to-consumer advertising has limitations,” 3.

  42. Brown, “Opening the Medicine Cabinet,” 5.

  43. See also Lexchin and Mintzes, “Direct-to-Consumer Advertising of Prescription Drugs: The Evidence Says No”; Moynihan and Cassels, Selling Sickness: How the World’s Biggest Pharmaceutical Companies are Turning Us All into Patients; and Critser.

  44. Calfee, “Public Policy Issues in Direct-to-Consumer Advertising of Prescription Drugs,” 174.

  45. Macias and Lewis, “A Content Analysis of Direct-to-Consumer Prescription Drug Web Sites.”

  46. My goal here is not to expose the sales strategies of pharmaceutical companies (that project has been taken up by others) but I do want to share, from Critser (2005), pertinent excerpts from a 2002 speech by Pat Kelly, then head of U.S. pharmaceuticals for Pfizer. Kelly is talking about the relation of compliance and drug sales. This is Critser paraphrasing Kelly: “The notion of a hard sell by a company to a helpless patient had to be turned into one of a smart choice made by a continually empowered partner” (114). This is Critser quoting Kelly: “That will help us build a partnership out of a relationship. We have to get closer to the customer, connecting and exchanging information” (114). The way to do that (paraphrasing again) is to support patient compliance (patients adhering to treatments) and patient persistence (patients sustaining treatments over time) (114).

  47. Holm, “What is Wrong with Compliance?”, 108.

  48. See Letts, “Patient Empowerment” and Funnell, “The Future of Patient Empowerment.”

  49. Hawkins, “The Changing Doctor-Patient Relationship,” 108.

  50. Picard, “Boomers’ Lifestyle a Ticking Bomb.”

  51. Kolata, “Maybe you’re not what you eat.”

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  1. Department of English, University of British Columbia, #397–1873 East Mall, Vancouver, BC, V6T 1Z1, Canada

    Judy Z. Segal

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Segal, J.Z. “Compliance” to “Concordance”: A Critical View. J Med Humanit 28, 81–96 (2007). https://doi.org/10.1007/s10912-007-9030-4

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