Takeaway
Many patients struggle to take their medications as prescribed. Asking "How often do you miss your medications?" instead of "Are you taking them every day?" helps clinicians uncover what's really happening.
Lifelong learning in clinical excellence | June 5, 2026 | 3 min read
By Amanda McArthur, PhD, Johns Hopkins Medicine
At a routine primary care visit, a patient shared he had leg pain that was significantly limiting his mobility. A review of his chart showed an A1c of 13.9%. The clinician emphasized that improving his blood sugar must be the top priority, as it’s important for overall health and managing the leg issues. The patient expressed deep frustration about his ability to keep blood sugar and pressure under control while unable to exercise.
The clinician tried multiple approaches to help. She reviewed the patient’s list of medications, including two oral glucose-lowering medications, which he confirmed taking. She suggested diabetes education classes for his diet, but the patient’s work schedule conflicted. She offered an endocrinology referral for insulin, but the patient was reluctant. When the clinician offered to prescribe a third oral medication instead, the patient accepted.
Both the patient and clinician were genuinely trying. But what never surfaced during the visit was that the patient was also struggling to take his diabetes medications as prescribed. As a result, the visit ended with a plan that wasn’t likely to help—adding a third medication to a regimen the patient was already struggling to follow.
The problem
At least half of patients with diabetes struggle to take their medication as prescribed, yet this often stays hidden during routine primary care visits. Clinical practice guidelines recommend routine counseling to support effective patient self-management. However, healthcare professionals often struggle with how to ask about adherence without coming off as accusatory or judgmental, and guidelines offer little practical advice.
Figuring out what works: conversation analysis
Extensive research has shown that high-quality communication improves outcomes like medication adherence. But knowing that communication matters doesn’t help with how to communicate effectively in the moment. Conversation analysis is a powerful method for identifying what works in practice by examining recordings of real-world clinical encounters and analyzing them turn by turn to identify patterns in how communication practices—like how a question is worded—shape what patients say next. This can generate concrete, practical tools tailored to specific clinical tasks. Our analyses of recorded diabetes care visits suggest two strategies for initiating conversations about medication adherence.
A two-pronged practical approach for clinicians
1. Ask about medication adherence directly.
Questions that dance around medication adherence rather than addressing it directly rarely result in disclosure. Medication reconciliation questions like “Are you still on the metformin?” are usually heard as asking about a current regimen, not day-to-day behavior. Patients can accurately answer “yes” while still missing doses or taking it incorrectly. Even questions investigating hyperglycemia like “Why do you think your sugars are so high?” rarely uncover medication nonadherence. Patients instead tend to answer by focusing on their diet.
2. Ask in a way that normalizes nonadherence.
Questions that emphasize what should be happening like “Have you been taking your medication every single day?” make it harder for patients to disclose nonadherence, as doing so feels like admitting failure rather than simply reporting reality. Normalizing nonadherence means framing questions in a way that treats it as normal or expected.
Examples of direct, normalizing questions:
1. “How often do you miss the metformin?”
2. “Some people, especially when they have to take medication twice a day, sometimes forget to take that evening dose. Are you have any trouble with it?”
By asking patients about medication nonadherence in a way that is both direct and normalizing, clinicians can both support patients in the difficult work of self-management and respect their autonomy and life circumstances.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.