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Sunday, May 2, 2021

"Adherence" at a family medicine clinic

"Our next patient is here for hypertension follow-up," says the resident I'm working with. "I started him on hydrochlorothiazide last visit. He probably didn't take his medication." It’s my first week at the family medicine clinic, and questions ran through my head: why may he not have adhered to his medication, what's his blood pressure today, what are his cardiovascular disease risk factors, but one that bothered me through the visit and after: why did we think that he hadn't taken his medication, and did that assumption impact his care?

How do health professionals predict whether patients are likely to “adhere” to medical advice or medications? And does the expectation itself affect the care received?

Based on socioeconomic status, race, or other social constructs, a provider may assume behavior or characteristics—such as non-adherence—about a patient. But what operates on individual levels has structural and epistemic scaffoldings. It’s important to see these individual biases as rooted in communities and histories because doing so makes clear that it’s a system that fails individuals, and not the failures of individuals. 

Perhaps the assumption of non-adherence was based on the patient's pattern of behavior, or the patterns of the underserved population the clinic serves in Stamford, CT. Indeed, Mr. LS, a Black man in his 50s, had an ASCVD risk of 10% and had been recommended to start a statin. He had requested to not start it and trial diet and exercise first, but there were multiple notes showing that he had not made diet or exercise changes in the past. It can be easy to justify resignation based on a person’s patterns of behavior in the past, and to place the blame on the individual at hand.

But individual behavior has much to do with the community which forms a person’s habitus, the different worlds we live in based on histories of inequality and subjugation particularly in that of the US: trust in institutions of power and authority such as medicine, neighborhood stratifications including food deserts and lack of access to healthcare, and a country whose equality of opportunity was also founded on the oppression of Black people. According to a 2019 study conducted by DataHaven, the income inequality of Stamford’s Fairfield County is highest out of 100 largest US metro areas: the top 5% of earners made nearly 18 times that of the bottom 20% disproportionately. Black and Latino residents, which make up the majority of the patients seen here at the Optimus clinic, have higher rates  of poverty and unemployment, 17% and 18%, respectively, compared to white residents, 5%. 

Stamford's shrinking middle class and demographic trends mirror the disparities of the country, as COVID-19 has sadly illuminated with Black Americans dying at three times the rate of white Americans as the pandemic accelerated. Just two weeks ago, shortly after the nation let out an uneasy sigh after the conviction of Derek Chauvin, 13-year-old boy Daunte Wright was shot in Minneapolis—one among the many shootings that followed. Health professionals cite the disparities in health outcomes such as a maternal mortality rate two to three times higher in Black women compared to white women. Everyday biases, stresses, and power differences faced by minority populations, including assumptions about adherence and behavior, are less visible forces underlying such measured statistics. They will take extra effort to overcome, but individual actions and responses in tandem with policy changes go hand in hand.

There are understandable reasons for resignation and assumptions for patients like Mr. LS: time constraints in a busy family medicine clinic with other patients to see and limits of reach physicians have into the social structures on top of patient care. Still, a better understanding of social and economic determinants of health can be a stepping stone to overcoming resignation. Mr. LS had taken a detailed report of his blood pressures, but he had not picked up his medications. The detailed report showed his initiative to make change; what was the barrier to picking up medications? And had he received effective counseling on diet and exercise? The expectation of lack of change likely prevented action that could have been taken, but was not, to address these questions. In practice then, the visit became a quick admonishment to pick up medications without much else—reinforcing individual rather than systemic failure unfortunately.

It was true that Mr. LS had not taken his medications, but the assumption and resulting response of resignation only contributed further to already elevated barriers to adherence. Change is not solely the burden of the individual provider, and yet, a culture of resignation—on the end of providers and patients themselves—feeds further into the cycle of disparities. I believe that the next time Mr. LS visits, we’ll be able to do more to help him, and all of us, build a society which values social recognition and the capacity to aspire.