In Episode 7 of the Skin Flint Podcast we invited Jill Maddison to come chat with us. Jill is Professor of General Practice, Director of Professional Development and Director of the BVetMed course at the Royal Veterinary College (RVC).
(00:00) John introduces the podcast topic, along with producer Paul and Sue Paterson - who introduces us to the topic of compliance as well as the guest, Jill Maddison, the professor of general practice at the Royal Vet College in London who is published on the subject of compliance with a strong practical background.
Chapter 1 - Understanding Compliance.
(02:53) Jill introduces herself and her specialities in compliance and clinical reasoning and how they meet.
(04:02) Sue asks Jill about the importance of compliance when administering medications and Jill points out it doesn’t matter how carefully the medication is chosen, if the client doesn’t administer it the therapy won’t be effective and this is often taken for granted in veterinary medicine.
(04:49) Sue asks Jill to define complicate and Jill shares that compliance, or adherence as it is often called, is where the owner gives the medication as prescribed, in terms of the frequency, dosage and length of treatment. A client not 100% compliant might miss doses or not finish a course.
(06:06) John then asks Jill to outline some of the issues which could arise from a loss of that compliance. Jills says that therapeutic success is better with closest to 100% compliance, but also with some classes of drugs such as antibiotics, poor compliance could lead to resistance to that drug because the plasma levels drop below the required amount. Then also in a long term treatment regime such as epilepsy there can be poor therapeutic outcome, but also the patient can need more drugs in the long term because they are not managed effectively, which could lead to more side effects. Also with pain management, they could be in more pain as a result of poor management of the pain due to an insufficient level of pain relief. And finally in diseases where the condition goes into remission but the drug should be continued, the client may stop the medication leading to the return or exacerbation of the issue. Jill uses the example of us with a cold for which we do end up on antibiotics, but then we stop them as we start to feel better because we forget to take it them.
Chapter 2 - Recognising Compliance
(10:53) - John asks what factors from an owners perspective would halt compliance to a therapy and Jill reflects that allergic skin disease is a very applicable condition to this problem, showing that if an owner doesn’t fully understand the reason for a therapy they may not comply and so more of the treatment may be needed long term, for example if they don’t understand that the disease won’t be cured. Jill points out this all comes down to the relationship between the client and the clinician, as communication is so important. She shares the results of an online survey, and trust was a common theme - with owners least happy with the consultation were the least likely to comply with the medication - with 80% of owners complying well but 20% very poorly and evidence showing these people made their own clinical judgment as a result of a breakdown in that relationship between client and clinician.
(16:39) Sue asks if this relationship is better or worse with a nurse, suggesting that they may find nurses more approachable. Jill says there are studies in human literature to suggest information was better received from nurses, and they were more likely to admit not compliance to a nurse - So Jill feels nurses are very important to this aspect of veterinary care, maintaining that communication and relationship with more dedicated time with the owner.
(19:00) Sue also points out nurses are generally better at speaking in plain English and Jill agrees they are excellent for demonstrating medications and educating owners, provided they themselves are educated properly in the therapy themselves.
Chapter 3 - Helping Compliance
(20:52) John shares this resonates with him personally from running a dermatology clinic, and how he came to understand the role of compliance through these ongoing conversations with clients. And also how the 20% of owners making their own clinical judgment may be more likely to share this with the nurse, precisely because they haven’t themselves suggested the judgment the client disagrees with. He asks Jill if there are any key things clinicians can work on covering with the client. Jill says the clients who are not asking questions are also the ones who aren’t compliant - so asking them the questions on what their particular issue with giving a medication might be is important in order to put in systems in place to help that; ‘naming the fear’ and finding a solution together.
(25:50) Sue then asks about topical medication and what sort of key questions should we be asking on those. Jill says with an ear drop for example, the first question is whether or not they can do it at all - talking through how we do it and how it needs to be done properly and asking them to demonstrate, but recognising that is in the artificial environment of the consult room.
(27:22) Sue asks about the complexity of therapy, where a clinician might have given the owner too much to do and whether we need to rationalise therapy. Jill says it is very clear from studies in human medicine that the more medications given the worse the compliance, so we must ascertain which medication is essential.
(29:34) Sue asks if it worth considering how compliant an owner is before choosing how much medication to give and Jill shares that the challenge with this is that we don’t know which ones are poorly compliant, so you have to treat all clients as potentially poorly compliant and spend time explaining the reason for the medication.
(29:26) Sue asks if different formats of communication such as visual support is useful, and Jill agrees that this can be really helpful as many may seek out unhelpful support on the internet anyway, also giving handouts to back up what you have told them in person and support materials on the particular condition they have.
(31:26) Sue thanks Jill and asks for any final thoughts and Jill feels like all the studies on compliance speak to our diagnostic recommendations as well, so using the same communications and relationship models to aid compliance in diagnostic regimes. And Sue and Jill roundup the thoughts on the conversation.
(35:35) John ends the podcast reflecting with Sue and Paul on the conversations and asking them what their worst example of compliance is.
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