“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”
Silence.
“Has the clindamycin lotion in the morning helped with dryness?”
Silence.
“How often do you put the creams on?”
Silence.
It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.
“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”
Silence.
“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”
Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.
The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?
Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.
These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:
P Never give an adolescent male more than two things to do.
P Ask for twice a day, hope for once.
P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.
When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”
In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.
Well, I can dream, can't I?
Those who analyze nonadherence point out factors that contribute to it or might help counter it.
The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.
Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?
I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?
Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.