The first reason a patient may not be improving is due to poor compliance, says Steven R. Feldman, M.D., Ph.D., director of the Psoriasis Treatment Center at Wake Forest University School of Medicine in North Carolina. Dr. Feldman recently spoke about patient adherence to prescribed treatments at the Rheumatology Nurses Society 9th annual conference recently held in Cleveland.
“If you ask psoriasis patients ‘Are you taking the medication the way the doctor prescribed?’ 40 percent will say, ‘No.’ The other 60 percent are probably lying,” he said. Countless studies point to incredibly high rates of non-adherence. Dr. Feldman cited a Denmark study in which researchers examined adherence rates for medications prescribed to patients for different skin diseases. Half of the psoriasis patients didn’t even fill their prescriptions.
And, “If you thought those diaries are of any use, forget it,” he said. Patients, studies show, lie. In one study, patients returned medication diary records that were apparently completed in one sitting. Others start out diligently completing diary entries, but slacked off toward the end.
Even in moderate to severe disease states, patient adherence can still be a challenge. Studies show the worse the quality of life, the worse the treatment adherence, he said.
“Having a bad disease does not make you take your medicine. In medical school, in my pharmacology class, I never heard about adherence. They told us everything you’d want to know about what effects blood levels: absorption, first-pass drug metabolism, volume distribution, metabolism of the drug and fecal and urinary excretion, but they didn’t mention the three most common factors that determine variation between actual patients: whether they use the medicine, whether they use the medicine and whether they use the medicine.”
Dr. Feldman offers these tips to ensure your patient takes their medication as prescribed:
The visit is truly the most powerful tool.
- Try different tactics: Give your patients your personal cell phone number to call in treatment outcomes, but “don’t preprint your cell phone number on your card.” Writing it by hand on the card in front of the patient makes the patient feel uniquely important.
- Put it in writing: Even the simplest of instructions. “One patient said that her previous doctor said, ‘Use Dove or Ivory.' But I’m absolutely certain the previous dermatologist said, “Use Dove NOT Ivory.’” Misunderstandings can occur in the smallest of ways.
“Context has an enormous impact on people’s thinking.”
- In treating children, consider the power of persuasion in a sticker chart to track medication usage.
- In treating teenagers, “remember what teenagers want more than anything, is to be like other teenagers.” Teens don’t respond well to orders, so instead of prescribing medicine with orders, try: “This treatment is the treatment that most teenagers use to make them better.”
- Accentuate the positive: Instead of saying the “Risk of side effects is one in 100,” say there is a “99 chance in 100” that you will not develop a particular side effect. “99” gives the impression of being on the winning side.
The Dental Floss Phenomenon
- Patients diligently take their medication every two weeks, one study showed. Why? It’s due to the bi-weekly doctor visit. “This is an extraordinary powerful affect. I often hear the mother of acne patients say, ‘Oh, it’s so frustrating you always catch him on a good day.’ Well, that’s because he started using the medicine three days before the doctor visit.”
- Instead of an 8-12 week follow-up appointment, consider a more frequent follow-up visit of within days of the initial visit.
Considerations for Selecting a Medication
- Choose wisely. Involve your patient in treatment planning. “There is one medication that works better for treating topical (diseases and ailments): It’s the one the patient wants to use.”
- Choose fast-acting agents
- Simplify the treatment. The less the patient has to do, the better.
Don’t Underestimate the Power of Dr. Google
“If they see it on Google, they believe it.” Patients place value on Google content, so before the end of the visit, show your patients some reputable online information about their condition.