Adherence, also known as compliance, has gained significant attention in dermatology and medicine, on the whole. Compliance refers to how well patients follow a treatment regimen. Adherence encompasses compliance and other health-related behaviors. The term adherence is preferable to compliance, as it implies a more reciprocal doctor–patient relationship. For the purposes of this article, compliance will refer to following the recommendations of a physician. In practice, often clinicians approach these concepts similarly. How do we get patients to follow our recommendations? This is a critical question because patient adherence, especially in dermatology, is abysmal.
Seeking compliance, however, is only part of the puzzle. While we aim to discover better ways to encourage patients to maintain a treatment regimen, our aim should not be to improve it, per se. Instead, we should facilitate patient internalization of their specific condition and its treatment options. A third response to influence, identification, also exists and will be discussed.
A study published in 1958 by Kelman illustrates the differences between compliance, identification and internalization1 (Figure 1).
Figure 1. Summary of conditions for compliance, identification and internalization.
Compliance may be thought of as following orders. Kelman refers to the basis for this response to be “means control.”1 In other words, patients will comply with a physician’s treatment plan based on the perceived or real authority of the physician in order to please the physician or to avoid upsetting the physician. The caveat is that compliance is best when those being influenced are in the presence of the influencing agent.1 Practically speaking, in medicine it is not feasible to supervise patient use of their medications. In medicine, we desire that patients use a given treatment so that we may take part in improving their lives. Very often however, we rely on the compliance approach, assuming our patients will take a medication because we said so. We often prescribe one topical or another, with little time spent educating the patient regarding treatment rationale. Initially patients use these medications, but then later lapse in frequency of use. Weeks or months later, a patient may return to the office frustrated and disappointed.
Identification, on the other hand, is based on the attractiveness of the influencing agent. In this response to power, people tend to perform a behavior in so far as it results in a sort of relationship to another. Identification tends to fizzle in the absence of a desired affiliation with the influencing agent, though the actual presence of the agent is unnecessary.1
One example is Gatorade’s “Be Like Mike” campaign. As I child, I drank countless bottles of Gatorade in hopes that I could be similar to Michael Jordan because I saw in him attractive traits I wanted to emulate, namely the ability to dunk a basketball. An example more relevant to clinicians happens regularly. Very often patients arrive at the clinic with a desired outcome in mind and express this to the physician. Patients refer to a friend or colleague who suffers from a specific condition and had wonderful results with a particular medication and desire the same medication and result. Similarly, this is observed when celebrities endorse medications. Phil Mickelson’s endorsement of etanercept (Enbrel) or Justin Bieber’s use of Proactiv are prominent examples relevant to dermatology. Patients often seek a desired relationship or affiliation with such celebrities. In these instances, the patient uses a medication as a result of a desired outcome seen in someone with whom they desire an association.
Internalization represents the response to influence most likely to result in lasting change. When the power of the person influencing another is based on credibility, internalization takes place. In this situation, a person embraces the proposed change in the absence of surveillance or a desired connection or relationship. Stated another way, internalization occurs when a proposed change is consistent with a person’s existing beliefs, values or desires.1
For example, as children many of us bemoaned household chores such as taking out the garbage or keeping the home clean. For some of us, it was not until college or later that we understood the necessity of such tasks. Now we willingly do these tasks because a clean, trash-free home is consistent with our desire for a clean living space. In relation to dermatology, sun protection provides a good example of how internalization of a condition can encourage and sustain sun protective behaviors. A colleague and close friend of mine had a loved one diagnosed with melanoma. Fortunately, it was melanoma in situ and was excised. While he increased his use of sunscreen, hats and so on, it was not until he also developed a more consistent approach to sun protection and sun avoidance.
If we apply these concepts in medicine, we should pursue patient internalization along with adherence. Instead of seeking only how better to get the patient to do what we recommend, be it through Emails or text messages, the question then becomes, “How can we help the patient see that a given treatment is consistent with their values, goals and desires?” or “How can we help the patient see this through our eyes?” Practically speaking, this could involve a brief outline of the causes of the disease being treated, followed by how and why a given treatment was chosen.2
Facilitating internalization may require more time and effort than seeking the preferred drug vehicle, though this is quite important.3 Improved patient education and communication will facilitate internalization. On the front end, this might take more time; however, if we take the time to educate our patients and help them see a particular condition through the lens of a physician, we will enable internalization and conceivably see improved adherence and outcomes, potentially saving more time than if we had done it incorrectly the first time around.
Habits take time to form and different ways of encouraging patients to use a medication aid in this endeavor. Improving adherence, while simultaneously building a foundation for internalization, will allow the patient to more fully understand and take ownership of their health. n
Dr. West is a first-year dermatology resident at Texas Tech University Health Sciences Center in Lubbock, TX.
Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Disclosure: The authors have no conflicts of interest to report.
References
1. Kelman, HC. Compliance, identification, and internalization: three processes of attitude change. J Conflict Resolution. 1958;2(1):51-60.
2. Robinson JK, Turrisi R, Mallett KA, et al. Efficacy of an educational intervention with kidney transplant recipients to promote skin self-examination for squamous cell carcinoma detection. Arch Dermatol. 2011;147(6):689-695.
3. Tan X, Feldman SR, Chang J, Balkrishnan R. Topical drug delivery systems in dermatology: a review of patient adherence issues. Expert Opin Drug Deliv. 2012;9(10):1263-1271.
Adherence, also known as compliance, has gained significant attention in dermatology and medicine, on the whole. Compliance refers to how well patients follow a treatment regimen. Adherence encompasses compliance and other health-related behaviors. The term adherence is preferable to compliance, as it implies a more reciprocal doctor–patient relationship. For the purposes of this article, compliance will refer to following the recommendations of a physician. In practice, often clinicians approach these concepts similarly. How do we get patients to follow our recommendations? This is a critical question because patient adherence, especially in dermatology, is abysmal.
Seeking compliance, however, is only part of the puzzle. While we aim to discover better ways to encourage patients to maintain a treatment regimen, our aim should not be to improve it, per se. Instead, we should facilitate patient internalization of their specific condition and its treatment options. A third response to influence, identification, also exists and will be discussed.
A study published in 1958 by Kelman illustrates the differences between compliance, identification and internalization1 (Figure 1).
Figure 1. Summary of conditions for compliance, identification and internalization.
Compliance may be thought of as following orders. Kelman refers to the basis for this response to be “means control.”1 In other words, patients will comply with a physician’s treatment plan based on the perceived or real authority of the physician in order to please the physician or to avoid upsetting the physician. The caveat is that compliance is best when those being influenced are in the presence of the influencing agent.1 Practically speaking, in medicine it is not feasible to supervise patient use of their medications. In medicine, we desire that patients use a given treatment so that we may take part in improving their lives. Very often however, we rely on the compliance approach, assuming our patients will take a medication because we said so. We often prescribe one topical or another, with little time spent educating the patient regarding treatment rationale. Initially patients use these medications, but then later lapse in frequency of use. Weeks or months later, a patient may return to the office frustrated and disappointed.
Identification, on the other hand, is based on the attractiveness of the influencing agent. In this response to power, people tend to perform a behavior in so far as it results in a sort of relationship to another. Identification tends to fizzle in the absence of a desired affiliation with the influencing agent, though the actual presence of the agent is unnecessary.1
One example is Gatorade’s “Be Like Mike” campaign. As I child, I drank countless bottles of Gatorade in hopes that I could be similar to Michael Jordan because I saw in him attractive traits I wanted to emulate, namely the ability to dunk a basketball. An example more relevant to clinicians happens regularly. Very often patients arrive at the clinic with a desired outcome in mind and express this to the physician. Patients refer to a friend or colleague who suffers from a specific condition and had wonderful results with a particular medication and desire the same medication and result. Similarly, this is observed when celebrities endorse medications. Phil Mickelson’s endorsement of etanercept (Enbrel) or Justin Bieber’s use of Proactiv are prominent examples relevant to dermatology. Patients often seek a desired relationship or affiliation with such celebrities. In these instances, the patient uses a medication as a result of a desired outcome seen in someone with whom they desire an association.
Internalization represents the response to influence most likely to result in lasting change. When the power of the person influencing another is based on credibility, internalization takes place. In this situation, a person embraces the proposed change in the absence of surveillance or a desired connection or relationship. Stated another way, internalization occurs when a proposed change is consistent with a person’s existing beliefs, values or desires.1
For example, as children many of us bemoaned household chores such as taking out the garbage or keeping the home clean. For some of us, it was not until college or later that we understood the necessity of such tasks. Now we willingly do these tasks because a clean, trash-free home is consistent with our desire for a clean living space. In relation to dermatology, sun protection provides a good example of how internalization of a condition can encourage and sustain sun protective behaviors. A colleague and close friend of mine had a loved one diagnosed with melanoma. Fortunately, it was melanoma in situ and was excised. While he increased his use of sunscreen, hats and so on, it was not until he also developed a more consistent approach to sun protection and sun avoidance.
If we apply these concepts in medicine, we should pursue patient internalization along with adherence. Instead of seeking only how better to get the patient to do what we recommend, be it through Emails or text messages, the question then becomes, “How can we help the patient see that a given treatment is consistent with their values, goals and desires?” or “How can we help the patient see this through our eyes?” Practically speaking, this could involve a brief outline of the causes of the disease being treated, followed by how and why a given treatment was chosen.2
Facilitating internalization may require more time and effort than seeking the preferred drug vehicle, though this is quite important.3 Improved patient education and communication will facilitate internalization. On the front end, this might take more time; however, if we take the time to educate our patients and help them see a particular condition through the lens of a physician, we will enable internalization and conceivably see improved adherence and outcomes, potentially saving more time than if we had done it incorrectly the first time around.
Habits take time to form and different ways of encouraging patients to use a medication aid in this endeavor. Improving adherence, while simultaneously building a foundation for internalization, will allow the patient to more fully understand and take ownership of their health. n
Dr. West is a first-year dermatology resident at Texas Tech University Health Sciences Center in Lubbock, TX.
Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Disclosure: The authors have no conflicts of interest to report.
References
1. Kelman, HC. Compliance, identification, and internalization: three processes of attitude change. J Conflict Resolution. 1958;2(1):51-60.
2. Robinson JK, Turrisi R, Mallett KA, et al. Efficacy of an educational intervention with kidney transplant recipients to promote skin self-examination for squamous cell carcinoma detection. Arch Dermatol. 2011;147(6):689-695.
3. Tan X, Feldman SR, Chang J, Balkrishnan R. Topical drug delivery systems in dermatology: a review of patient adherence issues. Expert Opin Drug Deliv. 2012;9(10):1263-1271.
Adherence, also known as compliance, has gained significant attention in dermatology and medicine, on the whole. Compliance refers to how well patients follow a treatment regimen. Adherence encompasses compliance and other health-related behaviors. The term adherence is preferable to compliance, as it implies a more reciprocal doctor–patient relationship. For the purposes of this article, compliance will refer to following the recommendations of a physician. In practice, often clinicians approach these concepts similarly. How do we get patients to follow our recommendations? This is a critical question because patient adherence, especially in dermatology, is abysmal.
Seeking compliance, however, is only part of the puzzle. While we aim to discover better ways to encourage patients to maintain a treatment regimen, our aim should not be to improve it, per se. Instead, we should facilitate patient internalization of their specific condition and its treatment options. A third response to influence, identification, also exists and will be discussed.
A study published in 1958 by Kelman illustrates the differences between compliance, identification and internalization1 (Figure 1).
Figure 1. Summary of conditions for compliance, identification and internalization.
Compliance may be thought of as following orders. Kelman refers to the basis for this response to be “means control.”1 In other words, patients will comply with a physician’s treatment plan based on the perceived or real authority of the physician in order to please the physician or to avoid upsetting the physician. The caveat is that compliance is best when those being influenced are in the presence of the influencing agent.1 Practically speaking, in medicine it is not feasible to supervise patient use of their medications. In medicine, we desire that patients use a given treatment so that we may take part in improving their lives. Very often however, we rely on the compliance approach, assuming our patients will take a medication because we said so. We often prescribe one topical or another, with little time spent educating the patient regarding treatment rationale. Initially patients use these medications, but then later lapse in frequency of use. Weeks or months later, a patient may return to the office frustrated and disappointed.
Identification, on the other hand, is based on the attractiveness of the influencing agent. In this response to power, people tend to perform a behavior in so far as it results in a sort of relationship to another. Identification tends to fizzle in the absence of a desired affiliation with the influencing agent, though the actual presence of the agent is unnecessary.1
One example is Gatorade’s “Be Like Mike” campaign. As I child, I drank countless bottles of Gatorade in hopes that I could be similar to Michael Jordan because I saw in him attractive traits I wanted to emulate, namely the ability to dunk a basketball. An example more relevant to clinicians happens regularly. Very often patients arrive at the clinic with a desired outcome in mind and express this to the physician. Patients refer to a friend or colleague who suffers from a specific condition and had wonderful results with a particular medication and desire the same medication and result. Similarly, this is observed when celebrities endorse medications. Phil Mickelson’s endorsement of etanercept (Enbrel) or Justin Bieber’s use of Proactiv are prominent examples relevant to dermatology. Patients often seek a desired relationship or affiliation with such celebrities. In these instances, the patient uses a medication as a result of a desired outcome seen in someone with whom they desire an association.
Internalization represents the response to influence most likely to result in lasting change. When the power of the person influencing another is based on credibility, internalization takes place. In this situation, a person embraces the proposed change in the absence of surveillance or a desired connection or relationship. Stated another way, internalization occurs when a proposed change is consistent with a person’s existing beliefs, values or desires.1
For example, as children many of us bemoaned household chores such as taking out the garbage or keeping the home clean. For some of us, it was not until college or later that we understood the necessity of such tasks. Now we willingly do these tasks because a clean, trash-free home is consistent with our desire for a clean living space. In relation to dermatology, sun protection provides a good example of how internalization of a condition can encourage and sustain sun protective behaviors. A colleague and close friend of mine had a loved one diagnosed with melanoma. Fortunately, it was melanoma in situ and was excised. While he increased his use of sunscreen, hats and so on, it was not until he also developed a more consistent approach to sun protection and sun avoidance.
If we apply these concepts in medicine, we should pursue patient internalization along with adherence. Instead of seeking only how better to get the patient to do what we recommend, be it through Emails or text messages, the question then becomes, “How can we help the patient see that a given treatment is consistent with their values, goals and desires?” or “How can we help the patient see this through our eyes?” Practically speaking, this could involve a brief outline of the causes of the disease being treated, followed by how and why a given treatment was chosen.2
Facilitating internalization may require more time and effort than seeking the preferred drug vehicle, though this is quite important.3 Improved patient education and communication will facilitate internalization. On the front end, this might take more time; however, if we take the time to educate our patients and help them see a particular condition through the lens of a physician, we will enable internalization and conceivably see improved adherence and outcomes, potentially saving more time than if we had done it incorrectly the first time around.
Habits take time to form and different ways of encouraging patients to use a medication aid in this endeavor. Improving adherence, while simultaneously building a foundation for internalization, will allow the patient to more fully understand and take ownership of their health. n
Dr. West is a first-year dermatology resident at Texas Tech University Health Sciences Center in Lubbock, TX.
Dr. Feldman is with the Center for Dermatology Research and the Departments of Dermatology, Pathology and Public Health Sciences at Wake Forest University School of Medicine in Winston-Salem, NC.
Disclosure: The authors have no conflicts of interest to report.
References
1. Kelman, HC. Compliance, identification, and internalization: three processes of attitude change. J Conflict Resolution. 1958;2(1):51-60.
2. Robinson JK, Turrisi R, Mallett KA, et al. Efficacy of an educational intervention with kidney transplant recipients to promote skin self-examination for squamous cell carcinoma detection. Arch Dermatol. 2011;147(6):689-695.
3. Tan X, Feldman SR, Chang J, Balkrishnan R. Topical drug delivery systems in dermatology: a review of patient adherence issues. Expert Opin Drug Deliv. 2012;9(10):1263-1271.
