Respect may be the key to stopping patient 'no shows'

People with HIV are more likely to keep their scheduled medical appointments—and their disease under control—if they feel their physician listens, explains things clearly and knows them as a person, not just a "case," new Johns Hopkins research suggests.

"If people feel their doctor really knows them and listens to them, they feel that doctor has their best interests at heart and may be more likely to follow ," says study leader Tabor E. Flickinger, M.D., M.P.H., a fellow in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine. "And such are more likely to see that doctor again, which can influence the success of treatment."

Flickinger says in HIV, more than in most diseases, strict adherence to a medical regimen—including taking every daily dose of prescribed antiretroviral therapy medication—can mean the difference between maintaining HIV as a chronic manageable disease and having it turn into an acute fatal illness. Getting patients to keep medical appointments also plays a critical role in keeping them healthy, and the researchers report online in the Journal of Acquired Immune Deficiency Syndromes that how doctors and their patients communicate behind the doors of the exam room appears to be a vital link in that process.

The findings suggest that improved training in communication and interpersonal skills may help not only to improve health and immune function, but also to reduce the spread of the disease.

The researchers analyzed interviews completed by 1,363 patients at the Moore Clinic for HIV Care at The Johns Hopkins Hospital between December 2004 and June 2009, as well as data from medical records. The patients were asked about with physicians, including whether the doctor treated them with dignity and respect, listened, explained things clearly, kept them involved in decision-making and got to know them.

The researchers found that patients who felt such respect were significantly more likely to make their scheduled appointments. They also found that 72 percent of patients with suppressed levels of virus in their blood kept their appointments, while just 59 percent of those with unsuppressed levels of virus did. Lower blood levels of virus—typically kept in check with antiretroviral therapy—are associated with reduced risk of disease transmission and a lower risk that the virus will mutate. When the virus mutates, antiretroviral therapy medication may stop working, causing the viral load to rise again. Another medication may work, but could carry worse side effects.

Overall, 66 percent of patients in the study were on and 49 percent had suppressed viral loads.

Other studies, Flickinger says, have focused on factors such as race, gender and socioeconomic status as factors influencing kept appointments. This one is the first, she believes, to look at patients' interactions with their doctors.

Only two-thirds of the patients in Flickinger's study regularly kept their appointments. Appointment adherence was significantly higher in patients who were white, male and did not use illegal drugs.

That means that one-third of patients don't keep their scheduled appointments. "There's a lot of room for improvement there," she says. "Even missing one appointment can be detrimental to long-term outcomes, as it may lead to missing doses of medication or failure to respond to changes in viral load."

Flickinger encourages doctors to go beyond good bedside manner.

"People really respond to personal respect and genuine interest," she says. "And our study shows that these behaviors impact treatment. The traditional model of the doctors telling you what to do and you doing it because they are the authority figure doesn't always work anymore."

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