Thursday, March 11, 2010

Ask Me 3 and Halloween

 After reviewing some of my old notes way back when Ask Me 3 was first being designed, the gaping hole in its  underlying premise became clear to me again.

The program is based on thinking that if you have patients model and mimic questions to ask the doctor, they will actually wind up using that specific verbal strategy.

The most clear evidence that this works is in contexts like Halloween.
Little kids, holding the hand of a parent, are coached endlessly,
say....."Tick or Treat"

say   "Thank you"

Surely we can do better.

Tuesday, March 9, 2010

Ask Me 3 fails to live up to its billing

In a recently published article ( Annals of Family Medicine) evaluating whether the much-touted ASK ME 3 Program really does improve patients' abilities to ask 3 important questions of their doctor, the study findings were disappointing.  I and many colleagues have been skeptical about the premise of AM3 over the years, and none of us are suprised about these findings.

The study found that patients in the program were no more likely to ask questions than a non-program population of patients. ( (Annals of Family Medicine 8:151-159 (2010   Annals of Family Medicine, Inc.)

The authors conclude that there is "no evidence that the  AM3 intervention results in patients asking their physicians a greater number of questions or more specific questions. The intervention did not improve adherence to treatment as we defined it, a finding consistent with previous studies that used similar, simple communication interventions"

The thinking behind Ask Me 3
The argument or conceptual model behind the Ask Me 3 program is that if patients ask good questions they will get better information and that will lead to better adherence to treatment recommendations.

Yet again, the authors suggest the predictable do-over with a less health literate population.
In trying to explain the failure of AM3 in their study, the authors state, "It is possible that AM3 might be more effective among patients who have lower health literacy skills."

I am concerned that the subtext here  goes something like this
- well maybe more educated, more health literate people don't need to practice asking specific questions of their physicians, but less educated, less health literate ( and perhaps less literate) people would benefit from this intervention. 

It's just a small, sidewise step to saying,
- if you're educated, learning to mimic questions and recite them back, parrot-like is probably not going to go over very well, but let's try it on the less educated. 

You see just about the same intimating in the conclusion of a 2009 RWJ funded study looking at the failure of the "clear and simple" Target prescription bottle labels to show any marked improvement in medication taking ( . In the Target case the authors concluded, "The label may have been more effective in improving understanding15 and stimulating adherence in Medicaid beneficiaries or the uninsured, who often exhibit lower health literacy, and our study did not evaluate these populations."
Shrank, et al., (2009) "Can Improved Prescription Medication Labeling Influence Adherence to Chronic Medications? An Evaluation of the Target Pharmacy Label" J Gen Intern Med

Neither group of authors in these two studies feels the need to explain why they're more optimistic for their programs when it comes to less educated or less literate, or even poor and uninsured people. 

Is it possible that what's passing for a coda on study re-design runs dangerously close to keeping alive old, hard to-die-biases and prejudices?