Why do you think compliance is such a chronic issue for so many patients?
“It’s human nature,” says Dr. Feldman. “We have our routines, and for many of us, taking medication is not part of our routine behavior. Trying to remember to do new things is difficult until we create a new pattern,” he notes. “And with medications, even when we do create a new pattern of behavior, we may feel it is too difficult or bothersome to continue. Other times, patients may not think a medicine helps, so they don’t use it (and it may be the medicine didn’t help because they weren’t using it well at first).” Dr. Feldman also observes that there are many other dimensions to treatment for skin disease (cost, messiness, etc.), and compliance issues come up with each of those.
In your experience working with patients and studying compliance issues, what have you learned about adherence patterns?
“First, many patients say they are using their medication (even reporting use in treatment diaries) when they don’t. They often don’t fill the prescription,” he explains. “When they fill and start on the medication, they may not use it very well, and use typically drops over time,” which, according to Dr. Feldman, explains the phenomenon of tachyphylaxis.
What bearing does trust between the physician and the patient have on compliance?
“Trust is critical and one of the factors we can control. Patients don’t take medicines because they trust insurers or drug companies; they take their medication because they trust the doctor who prescribed it,” observes Dr. Feldman.
What kind of tips can you offer your colleagues for increasing compliance?
According to Dr. Feldman, simply being aware of the possibility of poor compliance is helpful. He also offers several pointers for increasingly compliance: “One, make sure you appear caring. I know you are caring, but when it comes to affecting what patients do, whether you appear caring is far more important,” he notes. “Two, think about providing a treatment regimen that people are willing to do; try to keep it simple.” These instructions should be given in writing so patients know what they are supposed to do, he says. “Three, use side effects like jiu-jitsu, turn them to your advantage (for example by making patients think that the medication must be working),” says Dr. Feldman. “And fourth, use the timing of return visits to drive patients toward better adherence,” he notes. Few things are as potent as return visits for making people use their medications, Dr. Feldman offers. “Do these, and I think you’ll find medications work a whole lot better!” n
Dr. Feldman is a Professor of Dermatology at the Center for Integrative Social Sciences & Health Policy Pathology at Wake Forest Baptist Health in North Carolina. He is a nationally recognized expert and speaker on psoriasis as well as compliance issues in medicine.
Watch Dr. Feldman discuss psoriasis management on DermTube Journal Club:
Read Dr. Feldman’s article, “Viewpoints: Challenging Dogma in Psoriasis Care” in Practical Dermatology®: