Increasing patients’ compliance with their medications is one of the most frustrating parts of practicing dermatology. With some patients, you just know that as soon as they’ve left the exam chair, what you just told them is “out the window.” Yet, we can’t just throw our hands up and give up on trying to help patients comply with their treatment regimens.
While there are no foolproof methods for increasing compliance, there are some that we’ve found to be more effective than most. Here, we’ll share our insight on this matter to help you become more successful with this trying aspect of practice.
Compliance is the authoritarian medical term describing a given patient’s adherence to the specific demands of a treatment regimen.
Treatment outcomes are often directly correlated to compliance, or lack thereof.1
Decisions regarding topical, oral, or physical interventions should ideally be based on clinical presentation together with patient preferences, lifestyle demands, and assessment of the relevant risks and benefits.
In an ideal clinical world, all patients would be 100% compliant. Increasingly, recent data have proven that this is a far-from-true clinical reality.2 Non-compliance is extremely common; therefore, patients achieve suboptimal benefits from treatment. Perhaps compliance could be improved if both clinicians and patients weren’t delusional.
Delusional Physicians
A delusion is defined as a fixed, rigidly held belief, not based or supported by reality, that is intransient to logic.
How many of us are guilty of “delusional thinking” as the specifics of each treatment regimen flow from our mouths and prescription pads as we move from patient to patient?
We operate under the false assumption that our treatment plans, simple or complex, will be executed flawlessly by patients.
Our “delusional thinking” is buttressed by certain realities, i.e. we are scientists; we understand the etiology and pathogenesis of skin disease; our decisions are data driven, and we have a wealth of clinical experience. In this context, patients certainly must be aware that we know what is best for them, and thus full compliance will result.
However, the data do not support this assumption. Non-compliance is rampant throughout all medical specialties.
Our beliefs that we know what is best for patients are probably not congruent with patients’ preferences.
As dermatologists we know that UV exposure is bad for people; but the patients themselves probably see social (and perhaps even physiologic) value in UV and tanning that we largely ignore.3
It’s doubtful that many of our psoriasis patients believe that life-long use of messy ointments is consistent with their lifestyle demands or best interests.
Abandoning the Delusion of Compliance
Perhaps relinquishing our subconscious delusion of compliance and replacing it with an assumption of legitimate non-compliance may lead to enhanced outcomes.
Legitimate non-compliance validates the wishes, fears, limitations, and psychological struggles of the patient. Therefore, smell, texture, irritation, compatibility with cosmetics, taste, perception of risk or any other factor deemed important or unpleasant by the patient can be deemed real and acceptable reasons for legitimate non-compliance.
It’s incumbent upon us, the clinicians, to observe for these reasons for non-compliance and respond to them.
Unfortunately, patients’ feel they are often not heard or dismissed, resulting in unilateral decision-making by the physician. This can lead to poor rapport, anger and power struggles. All that inevitably lead to poor compliance.
Abandoning the delusion of compliance allows us to embark upon the quest for the “Holy Grail” of compliance: Patient Empowerment.
Empowered patients are confident and optimistic. The enhanced sense of control and power decrease feelings of anxiety and futility, which allow patients to remain focused and positive about treatment.
Empowered, patients feel they are making a choice rather than acquiescing to dictatorial demands. They, therefore, want to comply and are anxious to please.
The doctor who empowers is better liked and more respected, and patients will work harder for these clinicians. Hopefully, these feelings can be sustained long enough for patients to see the therapeutic benefit of complying.
Poor outcomes are frustrating for both patient and physician. Recognizing that poor compliance may be the cause of poor outcomes should not be an excuse to reduce physicians’ sense of inadequacy in helping patients heal. We are responsible for making the right diagnosis and prescribing the right treatment. We are also in large part responsible for developing and implementing a treatment plan with which patients can and will comply.
Tips on Keeping Patients Compliant
The foundation of good compliance begins with a strong physician-patient relationship. To our patients, we should be perceived as empathetic, knowledgeable, caring doctors who are worthy of trust. Patients should be involved in the treatment plan; their “buy in” helps promote good compliance.
An important point to remember is that keeping the initial treatment period short — perhaps limited to 1 week before the next appointment — makes a huge psychological impact on the perceived burden of the treatment plan.
Helping patients plan “how to comply” in concrete terms also helps. For example “if this works for your schedule, take your antibiotic every night after dinner. I know for me it is hard to remember my cream every night; maybe you can put your tube of acne gel on top of your tooth brush. That way it’s ‘in your face’.” Or, for some patients, calendars with an “X” placed each day after using medicine are useful.
With each visit, problem solve with patients if there are issues of compliance because of side effects.
Sometimes re-defining nuisance side effects, i.e. mild retinoid erythema or xerosis as “indicators of efficacy” can be enough to keep a patient going until the side effect abates and/or the skin problem improves.
Mild stinging or skin sensitivity can be nonchalantly referred to as “the power of the sting.” However, if a patient doesn’t accept the explanation and his or her alternative (albeit incorrect) interpretation falls within his or her delusional belief system, then change the regimen.
Remember, you will never win the battle of challenging a delusion.
Dealing with Delusional Patients
Patients present with their own array of false beliefs that make them vulnerable to “jumping ship” prematurely, thereby abandoning well designed and effective treatments. These “delusional beliefs” are often incorporated from a myriad of convincing sources including friends, parents, relatives, print media, infomercials, and the internet.
Examples include: “only natural” is safe, “red skin” means allergy, don’t compromise your immune system with antibiotics, drink more water, etc.
Heartfelt therapeutic statements such as “You are delusional!” or “Are you crazy?” are not recommended by us and will likely jeopardize the rapport!
Success is often achieved by offering therapeutic interventions that do not directly challenge the delusions. Challenging delusional beliefs will only lead to fortification of beliefs, anger, mistrust, and power struggles that you will lose. Consider the following approaches:
• Tacitly validate that you accept and respect your patient’s beliefs, unless the beliefs are truly jeopardizing his or her health and welfare.
• Offer treatment suggestions that seem to fit the patient’s, lifestyle, such as, “Let’s try a vitamin A derivative,” or “Let’s try to avoid antibiotics by using doses that do not alter the natural balance of bacteria and fungus in the body (subantimicrobial regimen).” We’ve found with trust and time, delusional beliefs can gradually diminish or even be relinquished.
• Seek more frequent patient contact through appointments, phone calls, e-mail messages, or text messaging can enhance compliance by buttressing your patients’ perceptions of support, caring and encouragement. These contacts can also serve to convey consistent accurate information about the etiology, pathogenesis, and realistic course of treatment that may gradually become incorporated into the patient’s perceptions.
• Consider ways to use patients’ delusional beliefs to your advantage. Consider the following example.
Patients with acne excoriee may believe their condition is caused by infection in the skin. Such patients can be told that manipulating the lesions may “spread the infection” and that the infection cannot be controlled until the manipulation is stopped. Giving a topical antibiotic pledget to gently apply instead is a treatment plan that fits the patient’s delusional beliefs. It’s important to listen to what patients tell you and tailor fit treatment to suit them.
Encapsulating the Delusion for Clinical Success
Rene DuBois stated “the greatest derangement of the human mind is to believe something because one wishes it to be so.” As clinicians, we wish not to be guilty of such cognitive derangement.
Give your patients the privilege of your eyes and ears in an accepting fashion. In so doing, they can feel and believe that you have heard them and non-judgmentally accepted their emotions and beliefs.
Allow patients the privilege of “legitimate non-compliance”. After all, you don’t live in their bodies nor are you subject to the messages, demands, and expectations of their unique worlds.
Rather than responding to their false beliefs with frustration and arrogance (although these are our legitimate feelings, too), try to respond with kindness and creativity. Why should we bother? Simply, because what frequently underlies non-compliance is confusion, emotional turmoil, personality disorder, and/or delusional thinking. All of these contribute to a great deal of psychic misery.
Why not honor the Hippocratic oath and alleviate suffering. Be a healer; you will feel better at the end of the day — or, even more profoundly, at the end of your career.
Increasing patients’ compliance with their medications is one of the most frustrating parts of practicing dermatology. With some patients, you just know that as soon as they’ve left the exam chair, what you just told them is “out the window.” Yet, we can’t just throw our hands up and give up on trying to help patients comply with their treatment regimens.
While there are no foolproof methods for increasing compliance, there are some that we’ve found to be more effective than most. Here, we’ll share our insight on this matter to help you become more successful with this trying aspect of practice.
Compliance is the authoritarian medical term describing a given patient’s adherence to the specific demands of a treatment regimen.
Treatment outcomes are often directly correlated to compliance, or lack thereof.1
Decisions regarding topical, oral, or physical interventions should ideally be based on clinical presentation together with patient preferences, lifestyle demands, and assessment of the relevant risks and benefits.
In an ideal clinical world, all patients would be 100% compliant. Increasingly, recent data have proven that this is a far-from-true clinical reality.2 Non-compliance is extremely common; therefore, patients achieve suboptimal benefits from treatment. Perhaps compliance could be improved if both clinicians and patients weren’t delusional.
Delusional Physicians
A delusion is defined as a fixed, rigidly held belief, not based or supported by reality, that is intransient to logic.
How many of us are guilty of “delusional thinking” as the specifics of each treatment regimen flow from our mouths and prescription pads as we move from patient to patient?
We operate under the false assumption that our treatment plans, simple or complex, will be executed flawlessly by patients.
Our “delusional thinking” is buttressed by certain realities, i.e. we are scientists; we understand the etiology and pathogenesis of skin disease; our decisions are data driven, and we have a wealth of clinical experience. In this context, patients certainly must be aware that we know what is best for them, and thus full compliance will result.
However, the data do not support this assumption. Non-compliance is rampant throughout all medical specialties.
Our beliefs that we know what is best for patients are probably not congruent with patients’ preferences.
As dermatologists we know that UV exposure is bad for people; but the patients themselves probably see social (and perhaps even physiologic) value in UV and tanning that we largely ignore.3
It’s doubtful that many of our psoriasis patients believe that life-long use of messy ointments is consistent with their lifestyle demands or best interests.
Abandoning the Delusion of Compliance
Perhaps relinquishing our subconscious delusion of compliance and replacing it with an assumption of legitimate non-compliance may lead to enhanced outcomes.
Legitimate non-compliance validates the wishes, fears, limitations, and psychological struggles of the patient. Therefore, smell, texture, irritation, compatibility with cosmetics, taste, perception of risk or any other factor deemed important or unpleasant by the patient can be deemed real and acceptable reasons for legitimate non-compliance.
It’s incumbent upon us, the clinicians, to observe for these reasons for non-compliance and respond to them.
Unfortunately, patients’ feel they are often not heard or dismissed, resulting in unilateral decision-making by the physician. This can lead to poor rapport, anger and power struggles. All that inevitably lead to poor compliance.
Abandoning the delusion of compliance allows us to embark upon the quest for the “Holy Grail” of compliance: Patient Empowerment.
Empowered patients are confident and optimistic. The enhanced sense of control and power decrease feelings of anxiety and futility, which allow patients to remain focused and positive about treatment.
Empowered, patients feel they are making a choice rather than acquiescing to dictatorial demands. They, therefore, want to comply and are anxious to please.
The doctor who empowers is better liked and more respected, and patients will work harder for these clinicians. Hopefully, these feelings can be sustained long enough for patients to see the therapeutic benefit of complying.
Poor outcomes are frustrating for both patient and physician. Recognizing that poor compliance may be the cause of poor outcomes should not be an excuse to reduce physicians’ sense of inadequacy in helping patients heal. We are responsible for making the right diagnosis and prescribing the right treatment. We are also in large part responsible for developing and implementing a treatment plan with which patients can and will comply.
Tips on Keeping Patients Compliant
The foundation of good compliance begins with a strong physician-patient relationship. To our patients, we should be perceived as empathetic, knowledgeable, caring doctors who are worthy of trust. Patients should be involved in the treatment plan; their “buy in” helps promote good compliance.
An important point to remember is that keeping the initial treatment period short — perhaps limited to 1 week before the next appointment — makes a huge psychological impact on the perceived burden of the treatment plan.
Helping patients plan “how to comply” in concrete terms also helps. For example “if this works for your schedule, take your antibiotic every night after dinner. I know for me it is hard to remember my cream every night; maybe you can put your tube of acne gel on top of your tooth brush. That way it’s ‘in your face’.” Or, for some patients, calendars with an “X” placed each day after using medicine are useful.
With each visit, problem solve with patients if there are issues of compliance because of side effects.
Sometimes re-defining nuisance side effects, i.e. mild retinoid erythema or xerosis as “indicators of efficacy” can be enough to keep a patient going until the side effect abates and/or the skin problem improves.
Mild stinging or skin sensitivity can be nonchalantly referred to as “the power of the sting.” However, if a patient doesn’t accept the explanation and his or her alternative (albeit incorrect) interpretation falls within his or her delusional belief system, then change the regimen.
Remember, you will never win the battle of challenging a delusion.
Dealing with Delusional Patients
Patients present with their own array of false beliefs that make them vulnerable to “jumping ship” prematurely, thereby abandoning well designed and effective treatments. These “delusional beliefs” are often incorporated from a myriad of convincing sources including friends, parents, relatives, print media, infomercials, and the internet.
Examples include: “only natural” is safe, “red skin” means allergy, don’t compromise your immune system with antibiotics, drink more water, etc.
Heartfelt therapeutic statements such as “You are delusional!” or “Are you crazy?” are not recommended by us and will likely jeopardize the rapport!
Success is often achieved by offering therapeutic interventions that do not directly challenge the delusions. Challenging delusional beliefs will only lead to fortification of beliefs, anger, mistrust, and power struggles that you will lose. Consider the following approaches:
• Tacitly validate that you accept and respect your patient’s beliefs, unless the beliefs are truly jeopardizing his or her health and welfare.
• Offer treatment suggestions that seem to fit the patient’s, lifestyle, such as, “Let’s try a vitamin A derivative,” or “Let’s try to avoid antibiotics by using doses that do not alter the natural balance of bacteria and fungus in the body (subantimicrobial regimen).” We’ve found with trust and time, delusional beliefs can gradually diminish or even be relinquished.
• Seek more frequent patient contact through appointments, phone calls, e-mail messages, or text messaging can enhance compliance by buttressing your patients’ perceptions of support, caring and encouragement. These contacts can also serve to convey consistent accurate information about the etiology, pathogenesis, and realistic course of treatment that may gradually become incorporated into the patient’s perceptions.
• Consider ways to use patients’ delusional beliefs to your advantage. Consider the following example.
Patients with acne excoriee may believe their condition is caused by infection in the skin. Such patients can be told that manipulating the lesions may “spread the infection” and that the infection cannot be controlled until the manipulation is stopped. Giving a topical antibiotic pledget to gently apply instead is a treatment plan that fits the patient’s delusional beliefs. It’s important to listen to what patients tell you and tailor fit treatment to suit them.
Encapsulating the Delusion for Clinical Success
Rene DuBois stated “the greatest derangement of the human mind is to believe something because one wishes it to be so.” As clinicians, we wish not to be guilty of such cognitive derangement.
Give your patients the privilege of your eyes and ears in an accepting fashion. In so doing, they can feel and believe that you have heard them and non-judgmentally accepted their emotions and beliefs.
Allow patients the privilege of “legitimate non-compliance”. After all, you don’t live in their bodies nor are you subject to the messages, demands, and expectations of their unique worlds.
Rather than responding to their false beliefs with frustration and arrogance (although these are our legitimate feelings, too), try to respond with kindness and creativity. Why should we bother? Simply, because what frequently underlies non-compliance is confusion, emotional turmoil, personality disorder, and/or delusional thinking. All of these contribute to a great deal of psychic misery.
Why not honor the Hippocratic oath and alleviate suffering. Be a healer; you will feel better at the end of the day — or, even more profoundly, at the end of your career.
Increasing patients’ compliance with their medications is one of the most frustrating parts of practicing dermatology. With some patients, you just know that as soon as they’ve left the exam chair, what you just told them is “out the window.” Yet, we can’t just throw our hands up and give up on trying to help patients comply with their treatment regimens.
While there are no foolproof methods for increasing compliance, there are some that we’ve found to be more effective than most. Here, we’ll share our insight on this matter to help you become more successful with this trying aspect of practice.
Compliance is the authoritarian medical term describing a given patient’s adherence to the specific demands of a treatment regimen.
Treatment outcomes are often directly correlated to compliance, or lack thereof.1
Decisions regarding topical, oral, or physical interventions should ideally be based on clinical presentation together with patient preferences, lifestyle demands, and assessment of the relevant risks and benefits.
In an ideal clinical world, all patients would be 100% compliant. Increasingly, recent data have proven that this is a far-from-true clinical reality.2 Non-compliance is extremely common; therefore, patients achieve suboptimal benefits from treatment. Perhaps compliance could be improved if both clinicians and patients weren’t delusional.
Delusional Physicians
A delusion is defined as a fixed, rigidly held belief, not based or supported by reality, that is intransient to logic.
How many of us are guilty of “delusional thinking” as the specifics of each treatment regimen flow from our mouths and prescription pads as we move from patient to patient?
We operate under the false assumption that our treatment plans, simple or complex, will be executed flawlessly by patients.
Our “delusional thinking” is buttressed by certain realities, i.e. we are scientists; we understand the etiology and pathogenesis of skin disease; our decisions are data driven, and we have a wealth of clinical experience. In this context, patients certainly must be aware that we know what is best for them, and thus full compliance will result.
However, the data do not support this assumption. Non-compliance is rampant throughout all medical specialties.
Our beliefs that we know what is best for patients are probably not congruent with patients’ preferences.
As dermatologists we know that UV exposure is bad for people; but the patients themselves probably see social (and perhaps even physiologic) value in UV and tanning that we largely ignore.3
It’s doubtful that many of our psoriasis patients believe that life-long use of messy ointments is consistent with their lifestyle demands or best interests.
Abandoning the Delusion of Compliance
Perhaps relinquishing our subconscious delusion of compliance and replacing it with an assumption of legitimate non-compliance may lead to enhanced outcomes.
Legitimate non-compliance validates the wishes, fears, limitations, and psychological struggles of the patient. Therefore, smell, texture, irritation, compatibility with cosmetics, taste, perception of risk or any other factor deemed important or unpleasant by the patient can be deemed real and acceptable reasons for legitimate non-compliance.
It’s incumbent upon us, the clinicians, to observe for these reasons for non-compliance and respond to them.
Unfortunately, patients’ feel they are often not heard or dismissed, resulting in unilateral decision-making by the physician. This can lead to poor rapport, anger and power struggles. All that inevitably lead to poor compliance.
Abandoning the delusion of compliance allows us to embark upon the quest for the “Holy Grail” of compliance: Patient Empowerment.
Empowered patients are confident and optimistic. The enhanced sense of control and power decrease feelings of anxiety and futility, which allow patients to remain focused and positive about treatment.
Empowered, patients feel they are making a choice rather than acquiescing to dictatorial demands. They, therefore, want to comply and are anxious to please.
The doctor who empowers is better liked and more respected, and patients will work harder for these clinicians. Hopefully, these feelings can be sustained long enough for patients to see the therapeutic benefit of complying.
Poor outcomes are frustrating for both patient and physician. Recognizing that poor compliance may be the cause of poor outcomes should not be an excuse to reduce physicians’ sense of inadequacy in helping patients heal. We are responsible for making the right diagnosis and prescribing the right treatment. We are also in large part responsible for developing and implementing a treatment plan with which patients can and will comply.
Tips on Keeping Patients Compliant
The foundation of good compliance begins with a strong physician-patient relationship. To our patients, we should be perceived as empathetic, knowledgeable, caring doctors who are worthy of trust. Patients should be involved in the treatment plan; their “buy in” helps promote good compliance.
An important point to remember is that keeping the initial treatment period short — perhaps limited to 1 week before the next appointment — makes a huge psychological impact on the perceived burden of the treatment plan.
Helping patients plan “how to comply” in concrete terms also helps. For example “if this works for your schedule, take your antibiotic every night after dinner. I know for me it is hard to remember my cream every night; maybe you can put your tube of acne gel on top of your tooth brush. That way it’s ‘in your face’.” Or, for some patients, calendars with an “X” placed each day after using medicine are useful.
With each visit, problem solve with patients if there are issues of compliance because of side effects.
Sometimes re-defining nuisance side effects, i.e. mild retinoid erythema or xerosis as “indicators of efficacy” can be enough to keep a patient going until the side effect abates and/or the skin problem improves.
Mild stinging or skin sensitivity can be nonchalantly referred to as “the power of the sting.” However, if a patient doesn’t accept the explanation and his or her alternative (albeit incorrect) interpretation falls within his or her delusional belief system, then change the regimen.
Remember, you will never win the battle of challenging a delusion.
Dealing with Delusional Patients
Patients present with their own array of false beliefs that make them vulnerable to “jumping ship” prematurely, thereby abandoning well designed and effective treatments. These “delusional beliefs” are often incorporated from a myriad of convincing sources including friends, parents, relatives, print media, infomercials, and the internet.
Examples include: “only natural” is safe, “red skin” means allergy, don’t compromise your immune system with antibiotics, drink more water, etc.
Heartfelt therapeutic statements such as “You are delusional!” or “Are you crazy?” are not recommended by us and will likely jeopardize the rapport!
Success is often achieved by offering therapeutic interventions that do not directly challenge the delusions. Challenging delusional beliefs will only lead to fortification of beliefs, anger, mistrust, and power struggles that you will lose. Consider the following approaches:
• Tacitly validate that you accept and respect your patient’s beliefs, unless the beliefs are truly jeopardizing his or her health and welfare.
• Offer treatment suggestions that seem to fit the patient’s, lifestyle, such as, “Let’s try a vitamin A derivative,” or “Let’s try to avoid antibiotics by using doses that do not alter the natural balance of bacteria and fungus in the body (subantimicrobial regimen).” We’ve found with trust and time, delusional beliefs can gradually diminish or even be relinquished.
• Seek more frequent patient contact through appointments, phone calls, e-mail messages, or text messaging can enhance compliance by buttressing your patients’ perceptions of support, caring and encouragement. These contacts can also serve to convey consistent accurate information about the etiology, pathogenesis, and realistic course of treatment that may gradually become incorporated into the patient’s perceptions.
• Consider ways to use patients’ delusional beliefs to your advantage. Consider the following example.
Patients with acne excoriee may believe their condition is caused by infection in the skin. Such patients can be told that manipulating the lesions may “spread the infection” and that the infection cannot be controlled until the manipulation is stopped. Giving a topical antibiotic pledget to gently apply instead is a treatment plan that fits the patient’s delusional beliefs. It’s important to listen to what patients tell you and tailor fit treatment to suit them.
Encapsulating the Delusion for Clinical Success
Rene DuBois stated “the greatest derangement of the human mind is to believe something because one wishes it to be so.” As clinicians, we wish not to be guilty of such cognitive derangement.
Give your patients the privilege of your eyes and ears in an accepting fashion. In so doing, they can feel and believe that you have heard them and non-judgmentally accepted their emotions and beliefs.
Allow patients the privilege of “legitimate non-compliance”. After all, you don’t live in their bodies nor are you subject to the messages, demands, and expectations of their unique worlds.
Rather than responding to their false beliefs with frustration and arrogance (although these are our legitimate feelings, too), try to respond with kindness and creativity. Why should we bother? Simply, because what frequently underlies non-compliance is confusion, emotional turmoil, personality disorder, and/or delusional thinking. All of these contribute to a great deal of psychic misery.
Why not honor the Hippocratic oath and alleviate suffering. Be a healer; you will feel better at the end of the day — or, even more profoundly, at the end of your career.
