Robert Gabbay, MD, PhD: The Role of Patient-Provider Communication in Medication Adherence

At the American Diabetes Association's 78th Annual Scientific Sessions, Robert Gabbay, MD, PhD, the chief medical officer and senior vice president of the Joslin Diabetes Center, sat down with MD Mag to talk about how medication adherence has evolved into a major problem for patients with diabetes, and how improving patient-provider communication could help solve it.

Robert Gabbay, MD, PhD, the chief medical officer and senior vice president of the Joslin Diabetes Center:

Medication adherence is a huge issue and it really, probably, explains a large part of why there's a gap between clinical trial data and the outcomes that one gets in the real-world outcomes—they're never quite as good. I think the most important piece of that is communication and how we communicate with our patients. An example I often use is: if you ask a patient, “Do you take your medication?” they're likely to say yes. If you were to ask, “Some people struggle with taking their medication all the time, how's it been going for you?” they’re much more likely to admit that they're not taking it, and then you can explore why.

[It’s about] being non-judgmental and asking open-ended questions. To say “what are some of the challenges with taking your medication every day?” Then, when we're suggesting to patients to advance therapy—which they often need—and begin new drugs, [we need] to really feel them out on that and engage in a conversation. It doesn't have to be terribly time-consuming, but [it needs to give] them the option for choice. I will often say, “You know, there are a few options here. We could do nothing, in which case, you know your A1c is high and so is your risk of complications, or we could think of a new medication. Here's medication 1 and here's medication 2,” and [go over] some of the pluses and minuses. Ask, “What would you like to do?” and when they choose the option, they're far more likely to be adherent.

If the conversation is really very brief—"It looks like your A1C is high, you're going to need another drug, I'm prescribing this, here you go”—that sadly doesn't work very well. I think that's why we have the adherence issues that we do.

Another important issue to bring up is a cost. It's often difficult for us as providers to know what the cost is for the patient based on their insurance and the various different plans that might exist. I often will tell patients, “there are a few drugs in this class, I'm going to prescribe this one, but if you find out at the pharmacy that it's really expensive and you can't afford it—let me know. We can find something else.” Or we can think of appealing to why this drug was really the ideal one for them.

Opening that door—that you're okay talking about the fact that they can’t actually afford medications [is important] because I think it's difficult for some patients to bring that up. They don't want to sort of seem like they can't do that. Some are very forthright, but some are not, and so, again, opening the door for that that conversation can make a big difference.

The one thing I would emphasize about that is: when I speak to providers, they're often [saying] “Well, I don't have the time to do that.” I would argue that some of what I just talked about doesn't take very long. I mean, it's a 30-second to a 1-minute conversation. Really, it doesn't have to take a lot of time, and you have time for it—especially if you know that they're not going to be adherent. If you don't do that, well then you're really wasting a whole lot more time because visit after visit, they're not getting anywhere and everyone's frustrated.

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