English The importance of the doctor-patient relationship in transplantology for improving adherence: a proposal for integrating medical curricula
10.13135/1971-8551/7114
L'aderenza nei pazienti trapiantati è una questione molto importante per il successo del trapianto. Ad oggi, molti pazienti trapiantati presentano la non-aderenza, che va dalla non-aderenza alle indicazioni sullo stile di vita e sull'uso di sostanze, alla non-aderenza ai farmaci immunosoppressori. Il rapporto medico-paziente gioca un ruolo fondamentale anche per quanto riguarda l'aderenza in trapiantologia, ma finora la formazione in questo ambito è stata poco considerata nei corsi di laurea in medicina e chirurgia. L'obiettivo di questo lavoro è quello di fornire dati sull'aderenza nei pazienti trapiantati e di cogliere le maggiori criticità relative alla relazione medico-paziente in trapiantologia, con l'obiettivo di proporre un'implementazione dei curricula medici nel campo della formazione alla relazione anche in ambito trapiantologico.
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1971-8551
7114
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Paolo Leombruni
Tutor
Doctor-patient relationship; medical education; adherence; non-adherence; transplantation
The importance of the doctor-patient relationship in transplantology for improving adherence: a proposal for integrating medical curricula
Text.Serial.Journal
https://ojs.unito.it/index.php/tutor
22
Original articles
2023-01-10
2022-11-09
2022-08-23
2023-01-10
1
Paolo Leombruni
2023/01/10
10.13135/1971-8551/7114
Università degli Studi di Torino
1971-8551
1
Doctor-patient relationship; medical education; adherence; non-adherence; transplantation
The importance of the doctor-patient relationship in transplantology for improving adherence: a proposal for integrating medical curricula
https://ojs.unito.it/index.php/tutor/article/download/7114/6157
22
                                                                                             VOL. 22, N. 1, 2023: 47 - 60
                                                                                           DOI: 10.13135/1971-8551/7114




      The importance of the doctor-

      patient relationship in trans-

      plantology for improving ad-

      herence: a proposal for integrat-

      ing medical curricula.
      Alberto Olivero 1, Marco Miniotti1, Mariagiulia Bailon1, Paolo Leombruni1
      1   Università degli Studi di Torino – marco.miniotti@unito.it (autore per la corrispondenza)


ABSTRACT
Adherence in transplanted patients is a very important issue for transplant success. To date, many
transplanted patients present with non-adherence, ranging from non-adherence to lifestyle and sub-
stance use advice, to non-adherence to immunosuppressive drugs. The doctor-patient relationship
also plays a key role with regard to adherence in transplantology, but so far little consideration has
been given to training in this area in medical and surgical degree courses. The aim of this paper is to
propose an implementation of medical curricula in the field of relationship training in transplantology
as well, in the light of the data on adherence in transplant patients and the critical issues concerning
the doctor-patient relationship in this field.


Keywords: Doctor-patient relationship; medical education; adherence; non-adherence; transplantation


ABSTRACTI

L'aderenza nei pazienti trapiantati è una questione molto importante per il successo del trapianto.
Ad oggi, molti pazienti trapiantati presentano non-aderenza, che va dalla non-aderenza alle indica-




                                                                                                                            47
                                                                      The importance of the doctorpatient
                                                 relationship in transplantology for improving adherence


zioni sullo stile di vita e sull'uso di sostanze, alla non-aderenza ai farmaci immunosoppressori. Il rap-
porto medico-paziente gioca un ruolo fondamentale anche per quanto riguarda l'aderenza in trapian-
tologia, ma finora la formazione in questo ambito è stata poco considerata nei corsi di laurea in me-
dicina e chirurgia. L'obiettivo di questo lavoro è quello di proporre un'implementazione dei curricula
medici nel campo della formazione alla relazione anche in ambito trapiantologico, alla luce dei dati
sull'aderenza nei pazienti trapiantati e delle criticità relative alla relazione medico-paziente in questo
ambito.


Parole chiave: relazione medico paziente; medical education; aderenza; non-aderenza; transplanta-
tion




TAKE-HOME MESSAGE
(1) the doctor-patient relationship is a key element in improving adherence in transplant patients
(2) the doctor-patient relationship in transplantology is an underdeveloped element in medical cur-
       ricula
(3) it is necessary to implement medical curricula with training in the doctor-patient relationship in
       transplantation to improve adherence




INTRODUCTION
The World Health Organization defines ad-              and wishes in determining whether, when
herence as "the extent to which a person's             and how medication should be taken".
behaviour - taking a medication, following             These definitions, however, tend not to
a diet and/or making lifestyle changes -               clarify a particularly relevant element when
corresponds to the recommendations                     it comes to adherence to prescribed thera-
agreed upon by a health professional"                  pies, namely clinical outcome. Satisfactory
(WHO, 2003). A Consensus conference                    adherence to medication is achieved when
held in 2009 sought to better define com-              the difference between what the patient
pliance, concordance, adherence and non-               takes and what is prescribed has no effect
adherence to treatment. Compliance is de-              on the therapeutic outcome. This definition
fined as "the extent to which a patient's              emphasises therapeutic outcome as op-
behaviour corresponds to the doctor's rec-             posed to specific drug intake or drug level.
ommendations".      Concordance is "an                 In this sense, a good definition of non-
agreement reached after a negotiation be-              adherence could be “deviation from the
tween a patient and a healthcare profes-               prescribed drug regimen sufficient to ad-
sional that respects the patient's beliefs             versely affect the intended effect of the

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regimen” (Fine at al., 2009). Non-               order to improve therapy adherence in
adherence to the prescribed treatment            transplant patients by means of training in
regimen in the case of solid organ trans-        the doctor-patient relationship in the spe-
plantation (chronic immunosuppressive            cific field of transplantation.
therapies) is an important cause of trans-
plant failure, with rejection of the trans-
planted organ and a high cost in several         IMPORTANCE OF THE DOCTOR-
areas (Rodrigue et al., 2013; Pruette et al.,    PATIENT RELATIONSHIP IN CLINICAL
2020; Fine et al., 2009). Prevalence of          PRACTICE
non-adherence ranges from 6,7% to 50%            The doctor-patient relationship is at the
or higher, with higher prevalence in kidney      heart of the concept of patient-centred
recipient and adolescents (Fine et al.,          care.
2009; Oliveira et al., 2016; Rodrigue et         It is outlined according to a number of
al., 2013; Pruette et al., 2020; Gokoel et       fundamental points (Mead and Bower,
al., 2020).                                      2000):
According to the WHO, there are five in-         1) The adoption of a biopsychosocial per-
terdependent dimensions that determine              spective, which does not only dwell on
adherence to treatment: socio-economic              biomedical aspects but also takes into
factors, disease-related factors, treatment-        account the cultural, economic, social
related factors, patient-related factors and        and psychological factors that charac-
health system-related factors (WHO,                 terise and influence the patient's health
2003). With regard to therapy-related fac-          (Engel, 1977);
tors, these may include the type of thera-       2) The vision of the patient as a person
py, duration, side effects and complexity of        and the understanding of the subjective
taking it. With regard to the disease or po-        meaning that illness takes on in his or
tential disease, these factors may concern          her experience;
the symptoms, the severity or disability it      3) The sharing of power and responsibility,
may entail, and its duration. Patient-related       so that, overcoming the paternalistic
factors may concern the patient's personal-         model, not only the doctor's compe-
ity and psychopathology, as well as the pa-         tence and clinical opinion are respected,
tient's socio-economic and demographic              but also the patient's decision-making
conditions. Furthermore, less specified by          autonomy;
the WHO, an essential factor is the quality      4) The therapeutic alliance, a concept de-
of the doctor-patient relationship (Grassi          veloped and studied mainly in the field
and Riba, 2021; Mathes et al., 2014; Gast           of psychotherapy, but also applicable to
and Mathes, 2019).                                  other health fields, which envisages a
Until now, transplantology training for             collaborative effort between patient and
medical students has been limited to the            therapist, the existence of an affective
surgical and purely biological field, ne-           bond between the two, and mutual
glecting the relational aspects in particular.      agreement on the treatment objectives,
The aim of this work is to propose an im-           correlated with the results obtained
plementation of the medical curricula in


                                                                                           49
                                                              The importance of the doctorpatient
                                         relationship in transplantology for improving adherence


    during therapy (Martin et al., 2000;
    Horvath and Symonds, 1991);                CRITICALITIES IN THE DOCTOR-PATIENT
5) The importance of also considering the      RELATIONSHIP IN TRANSPLANTS CAN-
    health professional as a person, as        DIDATES AND RECIPIENTS
    someone who participates in the rela-      The doctor-patient relationship in trans-
    tionship and influences its course.        plantology is complicated by a number of
The doctor-patient relationship is a rele-     critical issues concerning patients and
vant element in terms of outcomes and          healthcare personnel.
adherence in several diseases (Riedl et al.,   Several studies show that there is a higher
2017; Zolnierek et al., 2009; Kim et al.,      prevalence of substance use and psychiat-
2004; Deniz et al., 2021; Derksen et al.,      ric and psychological disorders in patients
2013; Stavropoulou, 2011). For example,        awaiting transplantation and in transplant-
a good doctor-patient relationship corre-      ed patients. As far as the liver is con-
lates with patient satisfaction with treat-    cerned, the number of patients coming to
ment, reduced severity of symptoms and         transplantation for alcohol-related prob-
improved quality of life (Birkhäuer et al.,    lems is increasing (Bataller et al., 2019).
2017). Furthermore, a study from 2021          Also in the post-operative period, alcohol
found that a good doctor-patient relation-     seems to be one of the main causes of
ship, in particular good communication         transplant failure (Listabarth et al., 2020;
and quality of information, improves self-     Dew et al., 2008). The use of other sub-
management skills in patients with chronic     stances also seems to be more prevalent
diseases (Brenk-Franz et al., 2021). Going     in transplant patients, such as the use of
into more detail, we can observe how the       cannabis in renal transplant candidates,
doctor-patient relationship is relevant for    who also have a higher prevalence of other
improving outcomes and adherence in            substance abuse (Stark et al., 2019). In
several chronic diseases, such as diabetes     general, substance use is a major cause of
(Soyoon et al, 2022; Hojat et al., 2011;       failure following transplantation and one of
Giocanti-Aurégan et al, 2022), HIV (Flick-     the risk factors for non-adherence (Dew et
inger et al., 2015), hypertension (Dalal et    al., 2008). With regard to psychological
al., 2021), cancer (Grassi et al., 2017),      and psychiatric issues, there is evidence of
asthma (Fan et al., 2021), tuberculosis        increased prevalence in patients on the
(Chen et al., 2020; Pandia et al., 2019)       waiting list for liver transplantation (Sara-
and rheumatological diseases (Georgopo-        cino et al., 2018), who have received liver
lou et al., 2020; Balsa et al., 2021).         transplantation in adulthood (Zhu et al.,
Although less investigated, some studies       2020) or paediatrics (Ünay et al., 2019),
report that a good doctor-patient relation-    who have received renal transplantation
ship is also relevant for improving adher-     (Zachciał et al., 2022) or heart transplan-
ence in transplanted patients, whether         tation (Loh et al., 2020).
adults, children or adolescents (Pumilia,      The problem of substance abuse and psy-
2002; Zawadzka et al., 2016; Fredereicks       chiatric co-morbidities is exacerbated by
et al., 2010; Kleinknecht et al., 2012).       the high prevalence of stigma towards
                                               substance use disorder and mental disor-

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ders by health professionals. Stigma is a        is offered by most universities, albeit with
multidimensional construct characterised         a reduced number of training credits (Ore-
by a range of negative attitudes, beliefs        fice et al., 2019).
and behaviours that lead to the exclusion,       With regard more specifically to the field of
rejection, blaming or devaluation of a per-      transplantology, several attempts to im-
son or group (Balasanova et al., 2020;           plement medical curricula with regard to
NASEM, 2016). Several studies have high-         knowledge in this field have been reported
lighted how stigma towards substance use         in the literature to date (Edwards et al.,
disorder is particularly present in the gen-     2005; Highet et al., 2021; George et al.,
eral population and healthcare profession-       2017; Radunz et al., 2015; Patel et al.,
als (NASEM, 2016; Yang et al., 2017; van         2013; Feinsteint et al., 2019), but few
Boekel et al., 2013), leading to isolation       with regard to training in the management
and devaluation of patients with these is-       of transplant patients (Coe et al., 2021).
sues, worsening clinical outcomes, increas-      In order to improve adherence and in light
ing self-stigma and reducing demand for          of the aforementioned critical issues and
treatment. Stigma towards patients with          peculiarities of transplant patients and the
substance use disorder has also been             healthcare professionals who care for
highlighted in medical students and pro-         them, we believe that an implementation
posals have been made to improve the             of the curricula of medical and surgical
curriculum in the direction of reducing          degree courses towards relationship train-
stigma (Balasanova et al., 2020; Moses et        ing in the field of transplantology is neces-
al., 2021). Also with regard to mental           sary.
health, several studies have shown that          Relationship training with transplant pa-
there is a high prevalence of stigma and         tients should take into account the critical
reduced knowledge of these issues in both        issues mentioned above, seeking to reduce
health professionals and medical students        stigma and implementing training on sub-
(Gervas et al., 2020; Riffel and Chen,           stance use disorders (Moses et al., 2021)
2020). Again, stigma can cause a reduc-          and mental disorders (Kunkle et al., 2022).
tion in the detection of these issues in pa-     Furthermore, relationship training should
tients and a reduction in access to care,        seek to improve empathy, as defined by
with a worsening of outcomes and, in             Hojat and colleagues in 2002 (Hojat et al.,
transplant patients, a reduction in adher-       2002), which has been shown to be a key
ence to treatment (Demian et al., 2021).         element in improving clinical outcomes
                                                 and adherence (Kim et al., 2004).
                                                 The aim of a specific course on the doctor-
A PROPOSAL FOR THE IMPLEMENTA-                   patient relationship in transplantology will
TION OF THE MEDICAL CURRICULUM                   be to improve knowledge about the char-
To the best of our knowledge, only a few         acteristics of transplant patients and to
universities in Italy currently offer training   improve the quality of the relationship, so
in the doctor-patient relationship during        that greater adherence in transplant can-
the course of medicine and surgery,              didates and recipients can be achieved. To
whereas training in the medical humanities       do this, our proposal for the implementa-


                                                                                            51
                                                               The importance of the doctorpatient
                                          relationship in transplantology for improving adherence


tion of medical curricula would involve a       Illness Clinicians Attitudes (MICA2), devel-
course comprising theoretical lectures and      oped by Kassam and colleagues (Kassam
an experiential component, which has been       et al., 2010), a 16-item scale to investi-
shown to be effective in learning about         gate stigma towards patients with mental
mental disorders and also in reducing the       disorders and also towards psychiatric
stigma associated with them (Deb et al.,        specialisation; the Substance Abuse Atti-
2019; Pandhi et al., 2020). Furthermore,        tude Survey (SAAS), a scale widely used in
the course should seek to promote the ac-       medical education to assess students' atti-
tive participation of students, with brain      tudes towards people with substance
storming moments and sharing of personal        abuse problems (Chappel et al., 1985).
experiences, considering the possibility of     At the end of the training, we expect an
a more practical learning part, with simula-    improvement in empathy, a greater pro-
tions of clinical cases in small groups with    pensity for patient-centred care and more
role-plays, as well as training in communi-     knowledge regarding the critical issues
cation skills, which have been shown to be      surrounding non-adherence in transplant
effective in increasing empathy (Batt-          patients, coupled with a reduction in stig-
Rawden et al., 2013; Fragkos and Cramp-         ma regarding mental health and substance
ton, 2020), also in learning about adher-       abuse.
ence (Stojan et al., 2017).
Finally, in order to assess the effectiveness
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