Patient non-adherence and physician clinical inertia are common problems in medicine. Using an interdisciplinary approach combining medicine, philosophy, psychology and behavioural economics, Professor Gérard Reach from the University Sorbonne Paris Nord proposes that they are symptoms of a crisis calling for a paradigm shift, the advent of a model of care that should take into account for both patient and doctor the complex thought that characterises human beings as persons. Within this conceptual framework, Professor Reach has also stimulated the development of a programme to promote hospitality in hospitals.
Globally, between a third and half of all medicines prescribed for long-term conditions are not taken as recommended. This has huge implications for patient health, as well as economic and societal costs. These costs include wasted medications, but also the increased demands for healthcare due to deteriorating health. Adherence does not relate only to medications; it could equally be applied to diet or lifestyle changes, such as smoking cessation and exercise. Two types of non-adherence can be distinguished: intentional and unintentional. Intentional non-adherence is an active choice by the patient, largely based on his/her preferences, beliefs and desires, while unintentional non-adherence may be due to barriers beyond the patient’s control, such as misunderstanding or simple forgetfulness. In 2003 the World Health Organization recognised the importance of patient non-adherence and published a report highlighting the relationship between non-adherence and negative impacts on care.
Professor Gérard Reach, at University Sorbonne Paris Nord, started his investigation from a novel point of view. He observed that patient non-adherence is often framed unfairly. Healthcare professionals should recognise that it is actually an option by default, and that adhering to medical prescriptions, what some patients do, requires effort. Patients may indeed consider that the reward of adherence in chronic diseases is not appealing because it is often abstract (avoiding complications of the disease), and remote. Actually, it is an award that is never received. Therefore, one may consider that the true question is not: why some patients don’t follow medical prescription, but rather: how is it possible that some patients take care of themselves. If one answers this question, one may find clues to improve patient adherence to medical prescriptions.
Professor Reach observed also that there is a second phenomenon that jeopardises the efficacy of medicine: the clinical inertia of doctors who do not follow best practice guidelines. Like patient non-adherence, physician clinical inertia has negative consequences for patient health, makes treatment less effective, and has a cost in terms of health care expenditures. Professor Reach understood that patient non-adherence and doctor clinical inertia represent homologous phenomena, i.e. having the same mechanisms: both patients and doctors are persons, i.e. beings endowed with a complex thought that may lead them to follow or not recommendations.
Until now, it has been difficult to combat patient non-adherence and physician clinical inertia, which could be justified when they are clearly against the patient’s interest. Professor Reach proposes that these two phenomena are therefore symptoms of a crisis in contemporary medicine. This leads him to propose that a paradigm shift is needed to overcome this crisis, in the same way that, according to Thomas Kuhn (1922–1996), the appearance of a crisis in science leads to a scientific revolution.
Currently, the mindset of medicine is largely dominated by that of evidence-based medicine (EBM), which is explained by the extraordinary progress of contemporary medicine over the last fifty years. In the spirit of its founding fathers, EBM aims to integrate the highest quality scientific knowledge, the experience of the physician and patient values to guide decision-making in the clinical management of patients. Professor Reach, however, argues that this approach overlooks the complex thought of patients and doctors. He highlights the gap between theory and reality and suggests that building a bridge between evidence-based medicine and real-life is likely to yield the best outcomes for healthcare.
“Healthcare professionals should recognise that non-adherence is actually an option by default, and that some patients adhere to medical prescriptions, which requires effort.”
Professor Reach observes that people are often surprised by these observations of non-adherence and clinical inertia and he proposes that they can be explained by an abduction-based approach. According to philosopher Charles Sanders Peirce (1839–1914), abduction is defined as the process of forming new hypotheses to explain surprising phenomena. However, these explanatory hypotheses must be tested and verified before being accepted.
Thus, he suggests that a process of abduction can be used to formulate explanations of patients’ non-adherence and doctors’ clinical inertia. Professor Reach proposes that one possible explanation for both phenomena is that they are caused at least in part by the fact that contemporary medicine seems to have forgotten that patients and health professionals are persons, i.e. beings endowed with complex thought. Reintroducing the person, both on the patient’s and the carer’s side makes it possible to develop a new model of care that benefits both protagonists of care. Essentially, his conception of a medicine of the person concerns therefore both the patient and the carer.
Professor Reach has authored a book discussing the philosophy of patient adherence. He hypothesises that part of the reason for patient non-adherence may stem from an inability to prioritise the future. This theory is mainly based on philosophical concepts such as weakness of will. This was an idea touched upon by Aristotle under the name of akrasia, literally lack of force (e.g. “I know it would be better for me to do X, yet I don’t do X”). The philosopher Donald Davidson (1917–2003) has proposed an explanation for the weakness of will: agents do not obey a rationality principle that tells them to act according to what, all things considered, they judge to be the best. Professor Reach proposes to add to this principle another principle, which he calls foresight principle, which tells agents to give priority to the future, even though the first principle tells them to give priority to the present because it seems more attractive. This could be a way for people with chronic diseases to accept long-term treatment. Habit formation may also be important here, as it avoids the need for the conscious cognitive effort of behavioural change.
Based on several empirical studies conducted over the last ten years, using questionnaires administered to people with diabetes, obesity and gout, Professor Reach has arrived at a psychosocial model of adherence in chronic diseases, highlighting several points where patient education can intervene to improve adherence: strengthening the sense of self-efficacy (internal locus of control, the feeling that one can have an effect on one’s fate), promoting the use of habit, and the quality of the relationship between the patient and health professionals, especially trust. In particular, the use of habit can be useful in leading to what he calls “non-intentional adherence”, avoiding the effort of implementing an intention. Other character traits were highlighted in these studies: being obedient or disobedient, cautious or risk-taking, optimistic or pessimistic, happy or sad. The identification of character traits as determinants of adherence has an obvious ethical application: people’s character cannot be changed, and treatment must be adapted to it.
Patient education aims to reinforce patients’ self-efficacy, helping them to self-manage long-term health conditions. Education may help with patient adherence as it provides patients with information on the pathology and the treatment and with the opportunity to better understand the meaning of changes in health behaviours that are recommended for the management of their chronic conditions. In addition, patient education has the virtue of promoting patient trust in the health care provider.
“A paradigm shift is needed to take into account the complex thought processes of patients and doctors.”
Professor Reach believes that the question of the ethics of patient education is not as simple as it seems at first sight. It is true that patient education is ethically necessary, because it allows the foundation of a true person-centred medicine that respects the autonomy of people who have a chronic disease. Patient education is thus the basis of the so-called shared medical decision. Taking up the four models of the physician-patient relationship proposed by Emanuel and Emanuel (1992), Professor Reach proposes an ethical definition of patient education: it is the pathway that quits the paternalistic model to the informative model in which the caregiver gives information to the patient, to the interpretative model in which the caregiver helps the patient define his or her own preferences, arriving to a deliberative model in which the caregiver states his or her own preferences. This allows patients to make an informed choice between their own preferences and what is offered to them by the caregiver. Importantly, the last word goes to the patients, and this is the only way to avoid making patient education a paternalism in disguise. The deliberative model assumes a choice by the patient between his or her own preferences and those stated by the doctor. However, it should be clear that only the patient can define his or her preferences. The doctor, if he or she considers that they are likely to be biased by dysfunctional beliefs, can, in an effort to persuade and without becoming manipulative, explain why they do not correspond to reality.
If we consider the verb ‘to care’ in its reflexive form, I take care of myself, we can make a transitive equivalence of the type: I take care of myself if I am concerned for myself and I am concerned for myself if I love myself. The same could be said of taking care of someone: the doctor takes care of the patient if he/she is concerned for him/her and if he/she loves him/her. This aspect of love — or friendship — is best defined by the Greek word ‘philia‘. For Aristotle, ‘philia‘ is “wanting for someone what one thinks good, for his sake and not for one’s own, and being inclined, so far as one can, to do such things for him”. (Rhetoric, 1380b36–1381a2). This is perhaps also the meaning of sympathy, which the philosopher Stephen Darwall in his Welfare and Rational Care (2002) refers to as the emotion one feels when faced with someone’s suffering that one can alleviate, and which goes far beyond empathy, which consists only in imagining that suffering. How, on this basis, can we fail to see that there is a place for love, in the sense of philia, and for sympathy in the care relationship?
There is another way of getting people to do what they would not be inclined to do spontaneously: the nudge, the concept of which was popularised by Thaler and Sunstein’s best-selling book (2008). It is a way of gently encouraging people to change their behaviour, rather than using coercion and sanctions. Nudges act by modifying the architecture of choice and they are implemented for the good of the people. The practice of nudge is often based on manipulation, and this has been the subject of ethical debate. However, it is important to recognise that nudge concerns generally a collective behaviour, whereas care is always an individual relationship that involves a patient, i.e. a person as an individual. In a nutshell, in medicine, persuasion is legitimate but manipulation is inadmissible. However, patient education is not immune to the risk of manipulating the patient for his or her own good, without the carers being aware of it. This risk is real and caregivers who engage in patient education should be aware of it.
The health care relationship is initially asymmetrical, since it involves a profession: it is absurd to claim that the patient and the doctor are equals: the doctor has a profession, and that is why the patient comes to consult him. In the same way, the baker knows how to make bread, and the customer comes to buy it from him. In this example, the object of the relationship is the bread. In the example of the therapeutic relationship, the same asymmetry exists. However, the object of the relationship between the doctor and the sick person is here the latter, which gives the doctor the power. This power is first the power to heal; however, the danger of power is the abuse of power, with all its possible consequences.
In a medicine of the person, a symmetry is reintroduced into this necessarily asymmetrical situation, since the two protagonists of the care share the feature of being a person. This adds to the asymmetry of the consultation the symmetry of a conversation. In such a conception of the medicine of the person, the place of a conversation becomes essential. It is a question of giving it time and it is perhaps here that the real obstacle to the development of a true medicine of the person lies.
“Medicine of the person: adding to the asymmetry of a consultation the symmetry of a conversation.”
Professor Reach has also led a working group of Assistance Publique — Hôpitaux de Paris (AP-HP) to evaluate and promote hospitality in hospitals. This is important when considering a hospital stay in the context of a medicine of the person. Are the patient’s needs being met and do they feel that they have been treated with quality, respect, and responsibility? Are they considered as persons? Asking the question of hospitality in the hospital is therefore relevant in the context of this reflection: the hospital is the place where the technicality of medicine is expressed at its highest level. It is also the place where the protagonists of care, health professionals and sick people, meet. Obviously, the technicality of the hospital creates the conditions for an asymmetrical relationship. Hospitality, by its fundamentally reciprocal nature, the word host meaning both the one who welcomes and the one who is welcomed, introduces into this relationship the symmetry that sums up the meanings of medicine of the person. Thus, developing hospitality in hospitals benefits both patients and carers.
As part of this, a hospitality awards programme was developed at Assistance Publique-Hôpitaux de Paris (AP-HP) to encourage hospitals to consider hospitality as a core value. An evaluation of the programme (2019) found that it was possible for hospitals to self-evaluate their levels of hospitality and that appealing to pride through an awards system may be an effective way to promote quality for the best patient care.
The person has been defined here as a being with complex thinking. Within this complexity, the presence of emotions is part of what is called cognition. In a purely technical medicine, there is no room for emotions, neither in patients nor in health professionals. This is the case in clinical trials, which are the basis of EBM. Spinoza (1632–1677) considered the existence of two categories of emotion, positive and negative, derived from joy and sadness respectively, such as pride and shame, pleasure and pain. Professor Reach proposes that a medicine of the person can be more effective if it gives priority to positive emotions. We have seen that non-adherence is the default option, while adherence requires an effort that patients can be proud of and for which they should be congratulated. We have also seen that the success of the hospitality programme of AP-HP leading to the awarding of a prize is linked to the pride of the carer teams who see it as recognition of their involvement in the core of their profession: care. According to Spinoza “Desire arising from pleasure is, other conditions being equal, stronger than desire arising from pain.” (The Ethics, IV, Proposition 18).
Addressing these topics and using a person-centred model of care under the name of medicine of the person will have important implications for the practice and teaching of medicine, along with a new focus for research studies. It would consider the complexity of human thoughts and allow a personalised approach to medicine that is built upon trust. Finally, bridges between philosophy, cognitive psychology, behavioural economics and ethics are crucial for understanding more, in a phenomenological approach, about the magic of the encounter between the person with a disease and his or her doctor.
This must be the subject of a reflection on the organisation of medical studies, which must not be satisfied with teaching a medicine of diseases, but a medicine of the person. At his university, Professor Reach has introduced such teaching in the first year of the curriculum since 2013, and since 2019, he has initiated a clinical philosophy course for third-year students, devoted to the study of the faculty of thinking.
How can your philosophical models best be translated into clinical practice?
I believe that the main obstacle to optimal care is medical time: caring for oneself takes time, and caring for someone takes time. The second obstacle is the difficulty of reconciling technicality and humanity, in a medicine whose progress, which is obviously to be praised, risks reducing the time left for the expression of humanity. One way of overcoming this obstacle is to change the mindset by strengthening the place of social sciences and humanities in medical studies, recalling the words of Osler (1849–1919): “Ask not what disease the person has, but rather what person the disease has.”
- Reach G. (2015) The Mental Mechanisms of Patient Adherence to Long Term Therapies: Mind and Care, Foreword by Pascal Engel, Philosophy and Medicine Series, Springer, 2015
- Reach G. (2015) Clinical Inertia, A critique of Medical Reason, Forewords by Jon Elster and Joël Ménard, Springer, 2015
- Reach G. (2005) The role of habit in therapeutic adherence, Diabetic Medicine, 22:415–20. https://doi.org/10.1111/j.1464-5491.2004.01449.x
- Reach G. (2008) A novel conceptual framework for understanding adherence to long term therapies. Patient Prefer Adherence. 2: 7–20. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770416/pdf/ppa-2-7.pdf
- Reach G. (2014) That’s not all technology, In: Technological Advancements in the Treatment of Type 1 Diabetes, D. Bruttomesso and G. Grassi, Eds., Karger, 2014, 250–258
- Reach G. (2015) Patient’s non-adherence and doctors’ clinical inertia: the two faces of medical irrationality. Diabetes Management. 2015; 5:167–180. https://www.openaccessjournals.com/articles/patients-nonadherence-and-doctors-clinical-inertia-two-faces-of-medical-irrationality.pdf
- Reach G. (2019) Temporality in chronic diseases and adherence to long-term therapies: From philosophy to science and back. Diabetes Metab. 45:419–428. https://doi.org/10.1016/j.diabet.2018.11.002
- Reach G. (2016) Simplistic and complex thought in medicine: the rationale for a person-centered care model as a medical revolution. Patient Prefer Adherence. 10:449–57. https://doi.org/10.2147/PPA.S103007
- Reach G. (2016) Patient education, nudge, and manipulation: defining the ethical conditions of the person-centered model of care. Patient Prefer Adherence. 10:459–68. https://doi.org/10.2147/PPA.S99627
- Reach G, et al. (2019) Pedagogical value of a hospitality awards programme. BMJ Open Qual. 2019 Sep 17;8(3):e000576. https://doi.org/10.1136/bmjoq-2018-000576
Professor Gérard Reach explores how to reconcile the high technicality of modern medicine with a humanity that considers both patients and carers as persons, defining a medicine of the person.
Health Education and Practices Laboratory (LEPS, UR 3412), Sorbonne Paris Nord University, Bobigny
Gérard Reach is Professor emeritus at the Sorbonne University Paris Nord. From 2016 to 2019 he was Quality and Hospitality Referent for the Paris-Seine Saint-Denis University Hospital Group of the Assistance Publique-Hôpitaux de Paris. He has been Professor of Endocrinology and Metabolic Diseases at Paris 13 University since 2001. From 1991 to 2003, he created and directed the INSERM U341 Research Unit (Biomedical Engineering and Diabetes) at the Hôtel Dieu de Paris, working on technical issues such as the possibility of immunoprotecting islets of Langerhans for islet transplantation and the development of a continuous glucose monitoring system. In 2002–2003, he was President of the Artificial Insulin Delivery, Pancreas and Islet Transplantation (AIDPIT) study group of the European Association for the Study of Diabetes. Appointed Professor of Medicine in 2001, he directed the Endocrinology-Diabetology-Metabolic Diseases Department at the Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, in Bobigny until 2016. From this move, he devoted his research activity, conducted within the Health Education and Practices Laboratory (LEPS, UR 3412), to a philosophical investigation of the phenomenology of the doctor-patient interaction. He was president (2012–2015) of a working group of the AP-HP’s Institutional Medical Commission (CME) on Hospitality. He is Fellow of the Royal College of Medicine of Edinburgh (FRCPEdin, 2008) and Member of the French National Academy of Medicine (2021). Due to his work relating to diabetes, Prof Reach was awarded the Roger Assan Prize by the French Diabetes Association in recognition of his contribution to the field (2018).