Building a Foundation

Erin Foster, MD, PhD, highlights the importance of building a strong patient-provider relationship as part of the eczema care plan and shares her go-to tips for improving adherence through this relationship.

Dr Foster is assistant professor at Oregon Health & Science University in Portland.

Transcript
Dr Foster: Atopic dermatitis is a chronic disease that people have to think about when they have it. They can think about it to put their treatment on or to use their treatment, or they can think about it when they're flaring.

The most important thing to me that I try to emphasize to my patients is that they have to understand and be on board with the treatment. We're all OK doing hard things, as long as we feel like it's worth it, as long as we feel like we're going to get some outcome that we're hoping for.

Eric Simpson taught me this. In his clinic, when he first had an appointment with a patient for the very first time, he said, "This is a chronic disease." He said, "That's treatable, but it's not curable." In my practice, I do the same thing. I try to liken it to something that they'll already know about, like maybe diabetes. You can control the symptoms. It doesn't have to control your life, but you have to integrate it into your routine.

I always pick something that I know everybody does. We brush our teeth, hopefully at least once a day, maybe twice. I say, "Medicines should be like brushing your teeth, because it's just daily maintenance of your skin, the same way that you're taking care of your teeth."

If you do not have a good relationship with your patient, if your patient doesn't trust you, then there will be no patient compliance. I like to enjoy my work. I like to come to work and feel like I'm helping people, and to feel like I'm not in a struggle with my patients. I figured out early on that the best way for me to do that was to improve my relationship with the patients.

There are a couple of simple things you can do. You can sit down when you're in the room with the patient. That has been shown to give the impression that you're spending more time with the patient, even if you're still in a rush. Then it's been studied that physicians interrupt their patients after 11 to 23 seconds of a patient speaking.

There was a really great JAMA commentary that basically said, "This is when you're missing out on the context of a patient's disease." This is when you miss out on why the patient is not able to afford their medicine or what they've not done well in the past with other providers.

Those are the tips and tricks that you can then get at the beginning of the visit, in those first 30 seconds of the interview with the patient, just by sitting there and not speaking. It's really, really hard. I occasionally have to sit on my hands, bite my tongue, because you have so much you want to share, and you have so much you want to say. "Yes, I've seen a million patients with eczema or atopic dermatitis, and here's how I can help."

If you are going to do anything, you have to build that relationship first. You have to have an empathetic relationship, and you have to understand where the patient's coming from.

One thing to realize is that patients have been putting all sorts of topical things on their body before they've come to your office. Reminding them or telling them for the first time that the topical steroid is not going to work to relieve the itch the day that they use it, that is a good way of managing expectations.

People will wonder, "When I put this on, why does it itch more? Why does it bother me more?" Instead of saying, "Oh, if you use it for a couple days, it's not going to work immediately. If you use it for a couple days, see how it goes." That's my first one.

The second one is close follow-up. John [name] taught me this. He called the patients 2 weeks after he'd seen them to make sure that they're fine, called them on his cellphone. Or he has them come back. "Come back in two weeks. We're going to do topicals from head to toe if you're in a terrible flare, and you're going to get better. I promise I will be there with you when we see you in two weeks."

Other things are I always provide a written instruction, and then I know that they're going to Google search. I don't tell them not to, and so I give them the right resources that I want them to see. I give the National Eczema Association. I give them accurate information about atopic dermatitis, because otherwise, they'll go out and find their own, and that's not helpful for our relationship.

In terms of shared decision-making, there's a very easy, quick way to do this, which is that you state, "There is a decision that needs to be made." Then you state, "Neither of us can do it alone." You state, "I have this medical knowledge, but you are the patient. It's your skin, and so we need to do this together." We know, from lots of research, that patients want to share decisions with their providers. We know that, from experience, that that makes them more invested in their care and more compliant. I always say, "You can always change your mind. We can increase or decrease the dosage or the strength of the medicine, but this is your choice, because it's your skin. You have to live in it, and this is the decision that you have to be comfortable with."

That was a longer version of what I usually say in clinic, so it doesn't take very long, but setting that context and that stage of, "I'm not going to tell you what to do, because what's the point of that? We're not going to accomplish anything if I'm just telling you what to do."

I have found that that works really well with patients. They are very happy to hear that. It fits with their lived experience, and it certainly makes for a much more satisfying visit and much more satisfying follow-up visits as well.