Resource • Article
The Building Blocks to Improving Patient Adherence in Dermatological Practice: Accountability, Practicality, and a Little “Nudge”
Source: Steven R. Feldman, MD, PhD, is a Professor of Dermatology, Pathology, and Social Sciences and Health Policy at the Wake Forest University School of Medicine in Winston-Salem, NC.
“Abysmal” Adherence for Dermatology Patients
Historically, adherence to topical treatments in dermatology has been poor due to a combination of factors:
- The complexity and inconvenience of treatment regimens.
- The unpleasantness and discomfort associated with multiple topical applications.
- The perceived inefficacy when results are not immediately visible.
Additionally, side effects (i.e., skin irritation), patient forgetfulness, and a lack of understanding about the importance of consistent use, further contribute to the overall state of poor adherence. These barriers often lead patients to discontinue treatment or disregard their treatment regimen, resulting in suboptimal outcomes and ongoing dermatological issues.
Dr. Steven R. Feldman, MD, PhD, a professor at Wake Forest University School of Medicine, is a leading authority in dermatology, pathology, and health policy. His extensive expertise has driven advancements in medical research and education, particularly in the critical area of patient adherence and treatment outcomes. Dr. Feldman emphasizes the alarming issue of poor adherence in dermatological care, one of the most significant challenges in medical practice. His co-authored article in the British Journal of Dermatology starkly illustrates this, with its striking title: “Long-term adherence to topical psoriasis treatment can be abysmal: a 1-year randomized intervention study using objective electronic adherence monitoring.”[1]
“Patient adherence to topical therapies is so poor that The British Journal of Dermatology allowed me to use the word ‘abysmal’ in the title of that study. You do not see ‘abysmal’ often in scientific writing.”
Dr. Feldman points to medical training as the main culprit for failures in patient adherence. He likens the gap of adherence training in medical school to a three-legged stool. “In medical school they teach us about two of the legs. We’re taught to make (1) the right diagnosis, and prescribe (2) the proper treatment, but we’re not good at teaching about the third leg of the stool – how to motivate patients to use their medicines. We are only trained to do two of those three important things…so the stool falls over.”
“When you plant lettuce, if it does not grow well, you don’t blame the lettuce.”
– Thich Nhat Hanh
The full version of this quote attributed to Thich Nhat Hanh, a renowned Buddhist monk and peace activist, reads: “When you plant lettuce, if it does not grow well, you don’t blame the lettuce. You look for reasons it is not doing well. It may need fertilizer, or more water, or less sun. You never blame the lettuce. Yet if we have problems with our friends or family, we blame the other person. But if we know how to take care of them, they will grow well, like the lettuce.”[2]
Just as a gardener meticulously adjusts various conditions to foster a plant’s growth, dermatologists strive to cultivate strong relationships with their patients, thereby promoting more favorable outcomes. The core of this concept lies in the pursuit of genuine insights to address challenges effectively. Rather than assigning blame when issues arise, physicians can instead focus on identifying strategies to support and nurture patient success.
Dr. Feldman applies this notion more directly. “We have great drugs. Amazing treatments that are almost miraculous in how effective they are if people use them…but that’s a big ‘if.’ As physicians, if our patients are not using the medicine, we have no place for blaming the patient. It’s not that the patient fails, it’s that the doctor has failed, because the doctor didn’t get the patient to use the medicine. It’s our responsibility.”
Building the Pyramid
In his book, “Practical Ways to Improve Patient Adherence,” co-authored with Daniel J. Lewis, Dr. Feldman addresses this shortcoming in physician training. The book explores various strategies to enhance patient adherence to prescribed treatments – placing an emphasis on the importance of understanding the barriers to adherence and offering practical tools and techniques for healthcare providers to encourage patients to follow their treatment plans.[3]
Dr. Feldman likens the process of improving patient adherence to constructing a 3-tiered pyramid. The first level is about establishing a solid foundation built on trust and accountability. The second focuses on addressing practical issues, making treatment as effortless as possible for patients. Finally, the third tier employs specific behavioral techniques that give patients that extra “nudge” to stay on track with their medication. .[4]
The Foundation: Trust and Accountability
A scenario that Dr. Feldman uses when instructing medical students about establishing a foundation of trust and accountability is the “Parable of the Piano Teacher.”
“Some doctors will tell their patients, ‘Put this on twice a day and I’ll see you back in three months’ – but that’s ridiculous. Nobody would hire a piano teacher who said, ‘Here’s your sheet music. Practice every day, and I will see you at the recital in three months.’ That would be absurd. Those results would be ‘Abysmal’,” Dr. Feldman explained, using that favorite keyword to drive home the point.
“Piano lessons would need to happen at least once a week. The lessons encourage the students to practice on their own, and the anticipation of the lesson is critical in building a sense of accountability. The same concept applies to patient adherence. Doctors are far worse than the fictitious piano teachers who say, ‘I’ll see you in three months with no lessons.’ Doctors are like piano teachers who say, ‘Here’s a prescription for your sheet music. I have no idea what it’s going to cost you, or whether your insurance company is going to pay for any of it. But I want you to practice it every day. Practicing may cause rashes, diarrhea, and possibly a serious infection. I will see you again in three months…oh, and if it doesn’t work, I will give you a second and possibly a third musical instrument to practice at the same time.’ The foundation of successful treatment is creating a sense of trust and accountability,” Dr. Feldman concludes.
“Humans are interpersonal beings, and that trait is totally underemphasized in medical training when it comes to adherence.”
— Dr. Steven Feldman
Another critical aspect of a strong foundation of trust and accountability can be seen in the enormous power of communal pressure. To illustrate this point, Dr. Feldman turns to the work of Muhammad Yunus, a Bangladeshi economist who won the Nobel Peace Prize in 2006 for founding the Grameen Bank, which pioneered the concepts of microlending and the microcredit. Microlending is an innovative banking model that provides small loans to impoverished individuals without requiring collateral. Yunus’s work has empowered millions of people to start small businesses, improve their living conditions, and escape the cycle of poverty.[5]
“A beautiful example of creating accountability in economics and charity can be found in the work of Mohammed Yunus and his micro-lending organization. They didn’t just give out a loan to a single person. No, they would create groups of 4-5 women who knew each other in everyday life. These groups would then meet once a week with a bank representative to discuss business development, marketing, and sales efforts. The dynamic of meeting with a bank official and peers created an enormous sense of accountability with multiple layers.”
Dr. Feldman continued, “I create this same sense of accountability when I start a patient on a new medication by giving them my card. I tell the patient that the card has my personal cell phone number on it. Let’s say today is Thursday. I tell them that I want them to call me on Sunday and let me know how the medicine is working for them. When they call on Sunday, sometimes I’m not able to answer the phone. But whether I answer or not, the behavior has already been shaped, and that powerful sense of accountability has been put into practice.
“Sometimes, they will leave me a message. ‘Dr. Feldman, I’m so glad you didn’t pick up because I didn’t want to bother you on a Sunday, but you said I had to call. I just wanted you to know that you were right; the new medicine is working like a miracle. I’m like 90% better already.’”
Practicality: Simplicity and Education
The “curse of knowledge” in medical practice refers to a cognitive bias where healthcare professionals, due to their extensive expertise, unintentionally assume that patients and colleagues have the same level of understanding. This can lead to communication barriers, as medical jargon and complex concepts may not be easily comprehensible to those without a medical background. Overcoming this bias is crucial for effective patient care and teamwork in healthcare settings.[6]
Dr. Feldman believes that adherence cannot be left to chance. “You must give instructions in writing, and you must be clear – in writing – about side effects that might stop people from using the medicine.” Taking side effects a step further, Dr. Feldman says, “Whenever there’s a side effect, you want to make it an advantage. I like telling patients that this may sting, but the stinging is a sign that it’s working!”
Developing a reminder system with a patient also improves adherence. Exploring the “when” and “where” to apply a medication can increase adherence.
“I had a fungal infection between my toes but could never remember to apply antifungal cream until I started keeping the cream on top of my socks in the sock drawer. It was a simple triggering mechanism – by seeing it before I put my socks on, I never forgot to apply it.”
Another aspect of the “practicality” layer of the adherence pyramid is packaging. Most medications are packaged in a way that allows them to get lost on our countertops. “Pharmaceutical companies package medicines in bottles that are hard to open, with bland beige colored bottles – it’s as if they’re designed to blend into any environment so that you don’t notice they are even there. Packaging can make a huge difference in adherence. For example, when birth control pills came out in the 1960s, they were reasonably effective, but when they changed the packaging to a model that told you which pill to take on which day, adherence to treatment dramatically improved.”
Reaching the Top of the Pyramid: Applying the “Nudge”
The concept of the “nudge” in behavioral economics refers to subtle interventions that steer people’s behavior in a predictable way without restricting their freedom of choice. Nudges leverage insights from psychology and economics to design environments that encourage better decision-making. By making slight changes in the way choices are presented, nudges can significantly impact individual and collective outcomes.[7][8] Beyond economics, nudges have found additional applications:
- Healthcare – promoting a healthier lifestyle
- Environmental Conservation – encouraging sustainable practices
- Education – improving student engagement and performance
In the book “Nudge” by Richard Thaler and Cass Sunstein, the concept of “anchoring” is explained as a cognitive bias where individuals rely too heavily on the first piece of information they encounter (the “anchor”) when making decisions. This initial information sets a reference point, influencing subsequent judgments and decisions, often leading to biased outcomes.[9]
Dr. Feldman uses “anchors” to help guide patient choices to lead them to better adherence and accountability decisions. Injectable biologics are a highly effective treatment for a host of dermatologic diseases. But there is a problem with injectables, as many patients are fearful of injections. Dr. Feldman uses the anchor to reset patient’s expectations and help them to overcome their fear.
“I explain to the patient that biologics are like insulin; they are given by injection. You are familiar with how patients with diabetes give themselves insulin injections twice a day, right? Well, this medication is not exactly like insulin – you only need to take this medication once a month.”
By comparing the biologic injection to the insulin injection, Dr. Feldman has altered the patient’s perception. The number of injections serves as the anchor, and the contrast between a twice-daily injection versus a once-a-month injection serves to soften the patient’s preconceived notions of injectables. However, the objective number of the once-a-month injection never changed – only the patient’s perception was altered.
Dr. Feldman uses other less subtle motivational techniques based on the patient’s age.
“If you want to get a child to use their medicine, it’s really easy…you just use a sticker chart. Buy a variety pack of age-appropriate stickers, and every time they use their medicine, they get a sticker.”
Nurturing improved adherence in teenagers takes more than a sticker chart. “I did a study on acne patients where we randomized them to just standard of care, or standard of care with a lot of visits, or calling them every day, or calling their parent every day and having the parent remind them to use the medicine. Calling the parent every day resulted in the lowest compliance of any of the four groups, and it was not at all surprising. If I want a teenager to use a reminder system, I can’t tell the teenager to use a reminder system; teenagers often resist being told what to do.
“Teenagers want to be like other teenagers. So, I tell them, ‘This is the medicine most teenagers are using in this situation, and many of my teen patients have been telling me they use a reminder system.’ I do not tell them which reminder system to use. Instead, I offer a few examples that have worked for other teens. ‘Some teenagers tell me they put a Post-it note on their mirror, others have told me they keep their medicine on top of their toothbrush. Whatever you come up with is fine. All I ask is that after you choose a system that works for you, could you do me a huge favor and send me a text message later this week and let me know what you’re doing?’’
Looking Forward: Applying the Clinical Trial Model to Improve Adherence
Adherence to treatment protocols in clinical trials is typically better than in real-life practice, as patients and clinicians are held to higher regulatory, quality, and safety standards to ensure accurate data collection and successful outcomes. This rigorous adherence, driven by close follow-up, data collection, and auditing, as well as by multiple (piano lesson-like) study visits doesn’t extend to the general patient-physician relationship post-trial.
The high level of care and accountability observed in clinical trials may need to be generated in everyday medical practice to maintain treatment adherence. Implementing simple measures, such as follow-up messages through electronic medical records, can potentially improve patient outcomes by ensuring they continue to take their medications correctly. This approach offers benefits to all stakeholders in healthcare, from pharmaceutical companies to doctors and insurers, ultimately enhancing patient care.
Dr. Feldman agrees, “It would cost almost nothing, and it would probably dramatically improve patients’ outcomes. Drug companies are in the business of helping people. Doctors are in the business of helping people. Insurers are in the business of helping people. Adherence, getting people to use their medicine better, is a win, win, win. Nobody loses.
“Whether we are the first dermatologist to see the patient or the fifth, we must remember that our responsibilities include more than simply making the right diagnosis and prescribing the right therapy. We must also do our best to get our patients to use their medications.”[10]
