Concordance: A Partnership In Medicine‐Taking

Edited by Christine Bond , Pharmaceutical Press, 2004, 177 pp. ISBN-10: 0853695725 This text is an ambitious and thoughtful attempt to define and operationalize the concept of concordance from a variety of perspectives, drawing from a wide range of related research. In the preface, the nature of concordance is rightly described as nebulous and various efforts to define this illusive concept are offered by chapter authors throughout the text. Most often, concordance is contrasted with a compliance model and it is further characterized by patient-centered rather than paternalistic approaches. Concordance is also described with a strong preference for patient autonomy and full patient participation in the therapeutic alliance. Views of concordance are provided from the theoretical, practical, research and policy perspectives. Most often likened to shared decision making and informed adherence, authors struggle to differentiate concordance from other models of clinician-patient interaction. Their deliberations are extremely thought provoking, and lead one to consider how a concordance model might work in actual practice, what implementation issues and dilemmas may arise, and how clinical outcomes may be affected. The authors argue that true concordance would result in patient beliefs and healthcare provider beliefs of equal weights, where ‘the most important determinations are agreed to be those that are made by the patient’ (p.5). How this ideal is achieved is perplexing, particularly when health behaviour change (medication taking, diet, smoking, alcohol, etc.) may be the therapeutic goal and facilitation of change is an approach often recommended by others. The examination of dimensions of concordance begins with a ‘personal view’ in chapter 1. Here, the historical context leading to the rise of concordance is presented. Concordance was initially considered to be a ‘radical change in culture’ redefining the practice of prescribing, the patient’s role, and the relationship between providers and their patients. In the concordant model, compliance was seen as neither sufficient nor necessary, but the overarching concern was instead ‘respect for the health beliefs of both doctor and patient’ (p. 5). The second chapter attempts to further define concordance by comparing and contrasting it with other models of patient-provider relationship. The point of a concordant approach here is described as ‘not necessarily to change patients’ behaviour but to bring these differences into the open for discussion and negotiation’ (p. 24). The patient’s perspective is the focus of chapter 3. Here, concordance is described as a process where patients and healthcare providers actively work together toward therapeutic relationship and effective treatment planning through an open exchange of beliefs, mutual understanding, and joint negotiation or compromise (p.29). The nature of communication in the healthcare encounter, changes in both provider and patient roles, the emergence of patient partnership, and the importance of respect for patients’ experiential knowledge are also discussed. Barriers and challenges to implementation of concordance are reviewed noting concern for the continuing imbalance of power between patient and provider and on-going potential for coercion. Chapter 4, The Prescriber’s Perspective is particularly thoughtful as it examines how the principles of concordance may be practically applied in clinical practice. This author acknowledges that practitioners are being asked to take a ‘leap of faith’ when adopting a concordant approach as its clinical effectiveness is largely unproven (p. 54). Further, although clinicians may embrace concordance where treatment options are fairly equivalent, a concordant approach may be concerning in situations where patients knowingly choose suboptimal treatment. Specific advice about how to use a concordant approach in practice is provided. The perspective of pharmacists and nurses is examined in chapter 5 with an emphasis on medication monitoring. There are few opportunities for these practitioners to enter into concordant-style discussions with patients, and these discussions are often limited to patient education about medications and treatment. In chapter 6, Educational perspectives on concordance, the four core aims of concordance are described as (i) relationship with patients; (ii) elicitation of patient concerns, expectations and beliefs; (iii) provision of information appropriate for the patient; and (iv) involving the patient in an agreed upon management plan (p. 96). These aims also reflect the basic tenets of shared decision making, but do not address adherence to the plan beyond the initial decision. A broad review of educational techniques for clinician communication skills teaching is reviewed. Perhaps some of the most interesting deliberations are presented in chapter 7, The theoretical basis of concordance and issues for research. In this chapter authors attempt to move from the concept of concordance to its implications for research. These authors argue that concordance should be operationalized in terms of informed adherence, and defined as ‘the degree or match or mismatch’ between patient beliefs and provider beliefs and/or scientific evidence (p. 124). Here the basic concepts of achieving equality between patient and provider beliefs, and the primacy of patient decisions are abandoned in favour of a partnership approach where healthcare providers not only elicit and negotiate beliefs but also challenge and attempt to change these beliefs or other interpretations that they consider erroneous. In the final chapter on policy (chapter 8), the important outcomes of concordance are identified as ‘measurable, cost-effective improvements in patient care and satisfaction’ (p. 165). Here too, informed patients and partnership are key, but another dimension is added – providing support for patients to implement their treatment plan according to the negotiated ‘concordant’ agreement. This author acknowledges continuing confusion about the meaning of concordance, and the tendency to equate concordance with adherence. This text raises important questions about the concept of concordance including: (i) What are the intended outcomes of a concordant approach? (improved medication taking? patient satisfaction? adherence to cost-effective, evidence-based treatments? partnership? patient empowerment? degree of agreement between patient and provider? etc.) (ii) How do you know if you have successfully achieved concordance? (iii) Does a concordant approach lead to improved physical or emotional health? (iv) What is the role of persuasion or other behavioral interventions by the health care provider? Perhaps the key unanswered question is, concordance to what end? If the goal is not adherence to some effective plan for treatment or improved health then what? While the concordance model appears to be promoted and accepted in the UK, it is less extensively applied in the US where patient- and relationship-centered models are more widely accepted. Arguably, concordance is consistent with such models, particularly given its focus on the consultation process, but it goes further. Additional features can include an explicit approach to decision-making by both provider and patient; awareness, discussion, and negotiation of differences in provider-patient perspectives; and support for the patient after a joint agreement is reached. Many more questions are raised than answered in this text, while at the same time an important contribution is made to a potential shift in thinking about how to view and address issues of adherence and compliance, and the relative roles of healthcare providers and patients within the medical encounter. Concordance can serve as an overarching construct for the selective use of a variety of skills for patient relationship, patient education, decision-making, and even adherence, but before that can happen, clear consensus on the meaning and purpose of concordance must be reached. Here, authors provide important fodder for a ‘concordance debate’ in an interesting and engaging format. I admit, I read this book twice as it made me think hard about my own beliefs about provider-patient relationship, clinical communication skills and the purpose of the medical consultation. Anyone engaged in teaching or research in provider-patient communication will find this text to be a valuable resource as well as a significant stimulus for re-examining one’s own assumptions about the content and purpose of medical interactions.