Background/Purpose: Patients have many reasons for medical non-adherence. Finances often contribute where even the insured may find the cost of medications prohibitively high. In rheumatology, with the advent of multiple biologic medications, the cost of treatment regimens has soared.  We therefore devised a structured clinical encounter for rheumatology fellows to assess how well they address non-adherence in a patient that has stopped his/her biologic medication secondary to a loss of insurance. 

Methods: The 9^thannual 2013 New York City Rheumatology Objective Self Assessment Clinical Exam (NYC-ROSCE) featured 5 stations each focusing on rheumatic diseases. In one of the stations we devised a scenario where a trained actor portrayed a patient with rheumatoid arthritis that had previously been well controlled on a biologic medication. The patient though in the encounter now comes into the office with a disease flare after having stopping their regimen because of unemployment and losing his/her insurance. The actor was instructed to be embarrassed at addressing this awkward financial issue. The fellows were then asked to assess why the patient had now become non-adherent with their biologic and offer potential solutions to the patient.

Results: 24 fellows participated from 7 NYC-area rheumatology fellowships. Fellows were observed and evaluated on a 9-point Likert scale (9:excellent) by both a patient-actor and an MD evaluator. At this station, the mean patient-actor scores for composure (7.38), partnering with the patient (7.29), professionalism (7.67) and empathy (7.04) were high and not significantly different from the MD evaluators. Fellows were also evaluated on a 4-point scale as to how well they assessed financial burden and whether the patient-actors felt judged regarding their financial status (1: not at all, 4: extensively). On average all fellows addressed finances to a certain extent (2.95) and the patient-actors did not feel very judged (1.8). Interestingly though only 58% of the patient-actors felt that the fellows truly found the cause of the non-adherence v 92% of the MD evaluators (p=0.02). If assistance with finances was offered, patient-actors were most offered a referral to social work (11/24), referral to a patient assistance program (11/24) and a referral to the Medicaid office (7/24). 

Conclusion: In our OSCE encounter, while the fellows were all very professional, the patient-actors felt that only 58% of them had truly addressed the root cause of non-adherence: a lack of insurance. All of the fellows addressed finances to a some extent which is perhaps why the MD evaluators felt that more fellows addressed the cause of non-adherence when compared to the actors. This difference in perception is key given that potentially fellows may not be sufficiently trained to examine the psychosocial issues that lead to non-adherence.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/addressing-medical-non-adherence-from-lack-of-finances-in-an-observed-structured-clinical-exam-of-rheumatology-fellows/