Physician Spotlight: Steven R. Feldman, MD, PhD

Steven R. Feldman, MD, PhD is a professor of dermatology at Wake Forest University School of Medicine in Winston-Salem, NC. He has published more than 500 studies on adherence in dermatology, and this work formed the foundation for Causa Research, a company that provides online surveys to patients to help boost adherence to treatment regimens. Dr. Feldman serves the chief scientific officer at Causa Research.

How big of an issue is adherence/patient compliance in dermatology?

Dr. Feldman: It is an enormous issue. When dermatologists prescribe treatment and patients don’t improve, it’s probably because of one of three reasons. Making the wrong diagnosis and prescribing the wrong treatment are probably not two of the three. The most likely reason is poor adherence. The second most likely reason may be poor adherence, and the third most likely reason is poor adherence. It shouldn’t be surprising that adherence is so poor in dermatology [because] we’ve paid so little attention to the issue. Books entitled “Comprehensive Dermatologic Treatment” have for years ignored the adherence issue altogether. All dermatology patients exhibit poor adherence, except for some tiny subset of anal-retentive patients (usually architects, engineers and CPAs). Poor adherence is common across age and gender. Mothers love their children, universally, but that doesn’t mean that they apply treatment to their children’s skin disease. There may be times when adherence is worse—for example, in depressed or in cognitively impaired patients—but we have to expect that even under the best of circumstances patients don’t use medications as recommended. I would avoid labeling anyone a non-compliant patient. It’s probably redundant. We also don’t have good, reliable measures for adherence in regular clinical practice. In research studies, we can use electronic monitors to tell when patients use medications, and those studies reveal an enormous adherence problem.

What is driving poor adherenve among dermatology patients?

Dr. Feldman: Poor adherence is driven by every possible dimension of human psychology. Forgetfulness may be the most common issue. Fear of side effects is another. Cost may be an issue for many patients.

Why is adherence worse with topical agents than systemic medications?

Dr. Feldman: Using a topical agent is much more time consuming and messy than orals. Also, it’s relatively easy to build taking an oral agent into a patient’s natural activities. If the patient eats breakfast every morning, they can put their pills in a seven-day reminder container on the breakfast table. It would be hard to miss taking the medication. Doing that with topicals is much more complicated.

How can we improve adherence to treatment/patient compliance?

Dr. Feldman: There are endless things we can do once we start to think about it. First, we need to give patients an experience that makes them realize we care about them and that builds trust. We need to prescribe treatments that patients don’t find worse than the disease. We need to prescribe treatment they can afford. We need to keep the treatment simple. We need to assure them that the medication is not excessively risky, and we need to make sure we’ve given patients adequate written instructions that assure they know how to use the medication. I’ve tried tons of different approaches and written books on some of the finer points, but one of the most critical methods is to hold patients accountable. The idea that we can give patients instructions to do a task every day and come back in eight weeks borders on ridiculous. We know that such an approach would never work for piano lessons. By telling patients to call to report their progress in 3-7 days, patients are almost forced to fill the medication right away and to use it well. I’m an academic and don’t see that many patients, so I can do this for my patients. Other offices might want to automate the process using the Internet, an approach for which my University has spun off a commercial company, Causa Research [http://www.causaresearch.com/], that offers such services.