Working With Patients to Improve Outcomes

Patient adherence is an ongoing conversation in medicine and dermatology. Studies have shown that patients can experience primary nonadherence,¹ known as failure to have a new prescription dispensed within a certain time,² as well as secondary nonadherence, or failure to adequately execute their prescription,³ for various dermatologic diseases.^4-6 What can a dermatologist do to help improve patient adherence and outcomes?

“You have to build the relationship first. You have to have an empathetic relationship, and you have to understand where the patient is coming from,” said Erin Foster, MD, PhD, an assistant professor at Oregon Health & Science University in Portland, in a recent video interview.⁷ Dr Foster’s clinical interests include mucosal and blistering disease, but she is actively researching how shared decision-making (SDM) can be a significant part of medical treatment and dermatologic care. She shared insights with The Dermatologist as to how working with patients and their families in the creation of the care plan may be crucial to a successful outcome.

Rather than a more traditional paternalistic model, SDM allows patients to take an active role in determining their care plan. A successful model creates a consensus on a care plan between the patient and their provider(s), aligning evidence-based practices with patient lifestyle and preferences.⁸ It recognizes that the patient and their families are the expert in their skin disease due to their lived experience and gives the patient autonomy. SDM is a growing practice within medicine, though there is some reluctance to embrace the model in daily practice as well as a lack of formal curricula for medical trainees. Even when it is applied, pediatric patients and minority patients need more widespread and consistent involvement.^9,10 Regardless, SDM has been shown to improve patient satisfaction, adherence, and treatment outcomes.^11,12

Through SDM, providers get to know their patients, how their disease impacts their life and well-being, and their preferences on products and procedures. In fact, it can be as simple as spending a few minutes in an appointment to look past the skin’s appearance and disease presentation and truly listen to what the patient has to say about their quality of life before offering choices and guiding the appointment based on their feedback.

“After trying lots of different opening questions, I’ve settled on ‘How is your skin?’ Then I stop talking and I let them tell me,” said Dr Foster. “What I find that I get from that experience is then I know where to direct the next set of questions. If I say, ‘How is your skin?’ and people say, ‘Great. I have this other concern,’ then we skip right to the next issue. But if I say, ‘how’s your skin?’ and they say, ‘I’m not sleeping at night,’ then we have to dig deeper. I really revert to medical school training, where we learn to ask those very basic questions,” she explained.

Dr Foster highlighted atopic dermatitis as an example where the patient’s adherence may often have a significant impact on quality of life. “The patient’s skin may look perfectly normal, but we know from many studies that the nerves are abnormal, the skin is abnormal,” said Dr Foster. “What I aim for with treatment is for the patient to be satisfied with their status. How do you find that out? I ask the patient how their daily life and sleep are going. In eczema, those are the two most important things,” she continued. Once dermatologists know how these two aspects—daily life and sleep—are impacted, they can dig deeper into how a patient with atopic dermatitis perceives their disease in other ways, from scratching to other bothersome symptoms or signs.

“I find that open-ended questions are the most effective, because if I try closed-ended questions, such as ‘Are you bothered by this?,’ patients rarely answer that question. Instead, I like to use questions such as ‘What bothers you most? What do you think is triggering it?’ Again, I actively try not to talk at the beginning, because I want to hear what they think. If they think it is something that they are eating, then we have that conversation; if they don’t, then I don’t talk about that stuff. If they think that it’s an allergy that they have, then we talk about the data suggesting yes, no, or maybe for that patient,” said Dr Foster. “We can get to their questions quickly and more easily just finding out their priorities at the beginning, so it saves time in the visit overall.”

Oftentimes partners, parents, or other caregivers need to be queried for insights as well. Dr Foster said dermatologists can ask a patient with eczema how they are sleeping, but it can be helpful to ask the family about their perception of the disease.

“The nice thing about [involving a caregiver’s insights] is that it de-escalates the pressure on the patient themselves,” explained Dr Foster. “It gives the reporting responsibility to the person around them and makes the patient realize that they have a support system that they didn’t know that they had or maybe hadn’t thought of as a support system.”

Simply put, SDM seems to go hand-in-hand with the patient’s relationship with their physician. In fact, some research has indicated that the patient-provider relationship as well as SDM can influence patient adherence to treatment.¹³

Another key point for dermatologists to remember is that patient satisfaction (which is often influenced by the patient’s perceptions of physician friendliness and empathy¹⁴) may have a contributory effect on patient adherence and outcomes of care.^15-18 So, in essence, it could be beneficial for dermatologists to get to know their patients beyond how their skin looks and truly consider what the patient wants out of their medical treatment. Dr Foster said that it just comes down to recognizing the patient as the living expert in their disease. “Just let them know that you’re interested in their experience as a patient, that you want to get to the root of their disease. It doesn’t have to make the appointment longer. I honestly think it just takes more time listening and much less talking than most of us providers are used to doing.”