The Parable of the Piano Teacher

Enhancing Patients’ Treatment Adherence

Drugs work well in clinical trials. Then they are approved, and they don’t work nearly so well. The difference is explained by adherence. In clinical trials, patients take their medications; in clinical practice, they don’t. 

Why is this? Well, perhaps the most important reason is that in clinical trials, patients return for visits to assess their progress at weeks 1, 2, 4, 8, 12, etc.  In real life, doctors give patients medications and tell patients to come back in 2 months or 3 months or maybe even 1 year. This difference in visit schedules has critical implications.

Which brings me to the title of this presentation, the parable of the piano teacher. My kids take piano lessons once a week, and at the end of 8-12 weeks there is a recital. The recital sounds great, because the kids are practicing regularly. Maybe not every day, but at least a few times each week. 

Imagine what would happen if a piano teacher said to their students, “Kids, we’re going to have a recital 3 months from now. Please practice every day, and you will sound great. We’re going to skip the weekly lessons, because they aren’t important. Just practice, and you will do well.” Surely the resulting recital would sound truly terrible, as the kids would likely not begin to practice until shortly before the lesson.

While it might seem ridiculous for a piano teacher to try this approach, this is how physicians typically manage patients on new drugs. We tell the patient, “Take this every day for the next 3 months. We’ll see you in 3 months to see how it is working for you.” It is no wonder that patients don’t take medications well.

What of the typical solutions that are used to promote better adherence? We might consider how well they would work for the piano teacher. Imagine that the piano teacher, embarrassed by how bad the recital went, decided to do something to get the kids to practice more. First, he or she could try explaining to the kids why it is important to practice every day; still, the next recital sounded bad. Then he or she might wonder if the instructions to practice every day need to be in writing; after giving the kids detailed, written instructions on what to practice, the kids still don’t practice regularly. The instructor might give the kids a device with an alarm that goes off every day to remind them it is time to practice; that might help a couple of the kids, but the recital would likely still sound terrible for the rest.   

We may have some patients who just need to be told what to do. But for normal patients, some kind of follow up shortly after starting on a new treatment—a visit, a phone call, or even an email message—may be needed to help assure that patients will follow through on their treatment.

Dr. Steven Feldman is a professor of dermatology and public health sciences at Wake Forest Baptist Medical Center in Winston-Salem, NC, where he studies patients’ adherence to treatment. He is also Chief Science Officer of Causa Reseach, an adherence solutions company (www.causaresearch.com), founder of www.DrScore.com and author of “Compartments” (www.compartmentsbook.com).