Milton Markowitz

The Inaccuracy in Using Interviews to Estimate Patient Reliability in Taking Medications at Home

AN IMPORTANT PART of the medical care of many chronically-ill patients is self-administration of oral medications at home over a long period of time. Many improvements in the care available for such patients rest in the development of new pharmacologic agents more effective and less toxic than their predecessors. As each new agent is developed, however, it must be submitted to clinical trials comparing it in effectiveness and toxicity with other drugs already in use. Such trials comparing several drugs presume that the patients assigned to receive the drugs being tested actually take their medications as prescribed. It is known, however, that patients vary

Why patients don't follow medical advice: A study of children on long-term antistreptococcal prophylaxis

Compliance with physicians instructions was studied in children and adolescents on oral penicillin prophylaxis against rheumatic fever. Several sociomedical factors were found to be associated with increased risk of noncompliance. This risk increases with the number of factors present. The data demonstrate the critical importance of sociomedical factors in the long-term management of chronically ill children and adolescents.

The decline of rheumatic fever: Role of medical intervention: Lewis W. Wannamaker Memorial Lecture*

IT IS A PRIVILEGE and an honor for me to present the first Lewis W. Wannamaker Memorial Lecture. However, whatever feeling of pleasure I might have in being so honored is greatly diminished by the realization that he is no longer with us. I first met Dr. Wannamaker about 25 years ago, When I joined the American Heart Association Rheumatic Fever Prevention Committee, which he chaired. Although still a young man, he was already well known and highly respected for his scientific achievement. I was practicing general pediatrics in Baltimore at that time, and was appointed to the Committee to represent the practitioners point of view. I recall being struck by Dr. Wannamakers knowledge and interest in many of the problems faced by clinicians in dealing with the Prevention Committees recommendations. It was refreshing to find a scientist of his caliber who was also concerned with the practical application of information obtained from epidemiologic and laboratory research. He maintained this concern throughout his life, and often took time away from his research to lecture and to write for clinical audiences. Whenever we met, he always found time to discuss problems, and I benefited greatly from his quiet wisdom and sound judgment. He did much to encourage me to continue my interest in rheumatic fever. Our last meeting was in Florida a month before he died, at a conference convened to reassess the recommendations for the management of streptococcal pharyngitis, now that rheumatic fever no longer is a significant problem in the United States. These recommendations had been based on studies done at Warren Air Force Base in Wyoming, which

Birth Control Knowledge and Attitudes Among Unmarried Pregnant Adolescents: A Preliminary Report.

In a preliminary report 169 unmarried adolescents predominantly black 85% in their middle teens registering for prenatal services in the Family Obstetrical Clinic of Sinai Hospital in Baltimore received a structured interview consisting of precoded items and open-ended questions by a trained interviewer in order to determine whether increased access to birth control was likely to decrease the incidence of premarital pregnancy. There was some degree of social disruption and/or economic deprivation for most of these teenagers. 53% had dropped out of school due to pregnancy. Patients came from working class families. 55% lived with both parents (in 1/3 of these 1 parent was a stepparent). Reports of sexual activity prior to pregnancy revealed most beginning relations 2-3 years after menarche 80% became pregnant the same year or year following first intercourse. More than 1/3 claimed to have had intercourse only 1 or 2 times before conceiving. Only 15% had relations more than once a week. 85% continued to see the father of the child. 2/3 were very upset when confronted with pregnancy. 41% had used some sort of birth control; 30% of these with some regularity. Condoms were most frequently used; douche suppositories jellies used by 22%. 7% were unable to define birth control and less than half the patients could identify at least 3 methods. The pill was the most frequently mentioned (78%) followed by condom (64%) and IUD (39%). Mass media and friends were the 2 greatest sources of birth control information. Most did not have access to birth control. 2/3 indicated a willingness to use contraception regularly. There were negative feelings on the safety and effectiveness of birth control.

Special articleThe decline of rheumatic fever: Role of medical intervention: Lewis W. Wannamaker Memorial Lecture*

IT IS A PRIVILEGE and an honor for me to present the first Lewis W. Wannamaker Memorial Lecture. However, whatever feeling of pleasure I might have in being so honored is greatly diminished by the realization that he is no longer with us. I first met Dr. Wannamaker about 25 years ago, When I joined the American Heart Association Rheumatic Fever Prevention Committee, which he chaired. Although still a young man, he was already well known and highly respected for his scientific achievement. I was practicing general pediatrics in Baltimore at that time, and was appointed to the Committee to represent the practitioners point of view. I recall being struck by Dr. Wannamakers knowledge and interest in many of the problems faced by clinicians in dealing with the Prevention Committees recommendations. It was refreshing to find a scientist of his caliber who was also concerned with the practical application of information obtained from epidemiologic and laboratory research. He maintained this concern throughout his life, and often took time away from his research to lecture and to write for clinical audiences. Whenever we met, he always found time to discuss problems, and I benefited greatly from his quiet wisdom and sound judgment. He did much to encourage me to continue my interest in rheumatic fever. Our last meeting was in Florida a month before he died, at a conference convened to reassess the recommendations for the management of streptococcal pharyngitis, now that rheumatic fever no longer is a significant problem in the United States. These recommendations had been based on studies done at Warren Air Force Base in Wyoming, which

463 HYPOPHOSPHATBMIC RICKETS IN BREAST MILK FED PREMATURE

Breast milk has been the universal standard of infant nutrition; the appropriateness of this in the very small infant has been recently questioned. A case of hypophosphatemic rickets in a 595 gm premature will be presented. The infant was begun on breast milk at 12 d. of age and nourished solely on breast milk until diagnosed at 5 mos. at which time x-rays showed marked rachitic changes and fractures in the long bones. Hyper-parathyroidism, Vit D deficiency, dependency and resistence, copper deficiency and inadequate Ca intake were excluded as etiologies. Inorganic phosphate content of maternal milk was normal. At time of diagnosis the pt. was hypercalcemic, hypercalcuric (3.2 gm Ca/gm Cr.), hypophosphatemia (1.6 mg/dl) and had normal alk phos. The tubular reabsorption of phosphate was > 99%.The hypercalcemia, hypercalcuria and hypophosphatemia conrected and the radiologic changes resolved with phosphate supplementation.This is the first reported case of hypophosphatemic rickets in a premature fed breast milk. We propose it has not been seen in infants fed proprietary formula because these have from 3 to 7 times as much inorganic phosphate as breast milk. With increased emphasis placed on feeding breast milk to small prematures this condition may become more common unless anticipated.

A Controlled Evaluation of the Effectiveness of Comprehensive Pediatric Care in Influencing Patient Compliance

ALVIN H.NOVACK (New Haven, Conn.): Dr. GORDIS, I want to indicate that it is important that we measure the differences between comprehensive and episodic care. I would, however, raise a question as to the definition of comprehensive care. I think you have measured the difference between comprehensive physician care versus episodic physician care. Comprehensive health care must be defined more broadly than just physician care and should include social and psychiatric (mental health) in addition to the usual medical, nursing, and dental health care.Secondly, it is important to consider the difference between comprehensive and episodic care. The latter is disease oriented, and the former is health promoting, and it is difficult to compare the two when one talks about a chronic disease and compliance.Dr, GORDIS: In response to your first question, it seems to me that in analyzing comprehensive care we have to study each of the components that go into it—each component individually as well as all the components together—if we are to find which factors are critical and which factors are extraneous. Although it is true that this study focused only on comprehensive care by a physician, the care was not restricted to a single organ system or set of problems. But I am in full agreement with you that different types of studies should also be done, including those of other health professionals, and in different settings.As far as it being disease oriented, I agree with you there, too. The problem is that the research in this area cannot be done cosmically; we must isolate the specific factors which we wish to analyze, and submit them to rigorous evaluation. I would suggest, therefore, that this type of study should be extended to preventive health services and health care, as well as to chronic disease management.WILLIAM OBRINSKY (Montefiore Hospital, New York, N.Y.): Comprehensive care is a way of life. It is not something that you can decide on one day to turn on, and a year later to turn off. You have had a population that has never had any experience with comprehensive care, and it takes a lot longer than 1 year to begin to teach the principles of comprehensive care. I would be very much interested in a similar study that might be done with a population who from very early infancy had comprehensive care over a longer period than 1 year.JOEL J.ALPERT (Childrens Hospital Medical Center, Harvard Medical School, Boston, Mass.): Dr. GORDIS, I agree with your expressed philosophy very much. We need controlled evaluations of comprehensive care. The challenge, however, is not only to try to measure differences but also to offer explanations as to why differences were or were not found. Thus, other points might be that these were families that were engaged in an identical physical place; that this was care given to individual patients and not to families.Your report is very similar to some of our own work. We did not measure differences in the first year of our study on 551 families but saw differences in the second and third.We also found that many of these measured differences disappeared in the third year of the study and these disappearing differences were due to those families on welfare who were pulled back into what we call the welfare-fragmented system by pressures outside of the comprehensive care program. What may, indeed, be needed is a total change in the health care system. Perhaps you have also identified a very complex population. I wonder how many of your 77 patients were on welfare.Dr. GORDIS: Only a relatively small proportion were on welfare, but the group was too small to be able to subject it to this type of analysis.I would like to make it clear that we are not suggesting that the lack of positive findings here applies to comprehensive care programs in general. We suggest only that this approach be used to submit comprehensive care to a truly rigorous evaluation of its effectiveness.BARBARA M. KORSCH (Childrens Hospital, Los Angeles, Calif.): If, as has been stated, this may not have been an example of truly comprehensive care, in that it was not delivered by a health team and did not start at birth, on the other hand, it did seem to isolate the factor of continuous medical care by one physician. Here again, it seems to me that there are other studies, like the one by CHARNEY et al. where continuous care by a particular pediatrician did seem to make for increased compliance with various medical regimes studied previously.So it is not a simple situation, even if you say that you are simply introducing the factor of the continuous relationship with a doctor. The question is: Can you legislate this in a hospital setting at one moment, and produce a change, or can you not?To document the study, you may need larger numbers of cases, because in our earlier work on compliance with medical advice we did have some very discouraging months during the first few hundred cases, and finally the zeros before the ones began to appear after we were well beyond 600 or 700 patients. This was an outpatient department. I do not think that the findings in this number necessarily mean that you might not get a real difference.There are several other points that interested me. I would be very curious to do some studies on the actual interaction between the physicians in the two systems and their patients, because our work has shown some statistically significant differences in patients following medical advice which could be predicted on the basis of specific attributes of an individual interaction of a new physician with a new patient around an illness, and I would be curious to see how the physicians in the two groups relate to patients, and how they communicate with their patients.Finally, lest someone get the impression that the fact of having a continuous relationship with a doctor like this does not improve patients follow-through on medical advice. When we started our studies we had done some work that suggested that perhaps the social distance between the physician and the patient might make the patient more compliant, in the sense that he is a big authority, and you cannot get too close to him, and maybe what he says might be more important, and therefore you were anxious to do what he said. We found exactly the opposite to be true in our compliance study; namely, that effect, and friendliness, and conversation other than strictly medical conversation, had a positive effect on compliance.EDGAR J.SCHOEN (Kaiser Foundation Hospital, Oakland, Calif.): The authors considered they were delivering comprehensive care. Did the patients?You mentioned that two senior residents were used. What was the total number of physicians involved in this work? Also, at the end of the study, were the patients asked at any point if they knew the name of their doctor?Dr. GORDIS: The same two physicians provided all the care for the comprehensive care group. In response to your second question, on the identification of the physician by the patient, there were significant differences between the two groups in the percentage of who could correctly identify their physician by name.NICHOLAS M.NELSON (Boston, Mass.): I would like to suggest that your slide which showed an increase in noncompliance in both the experimental and control groups is yet another demonstration of the uncertainty principle, or as it is sometimes known, the Hawthorne effect; namely, that it is impossible to observe the phenomenon without changing the phenomenon observed.President DAY: I think we will have to close the discussion.