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The authors of a new review in focus on the challenge of patient adherence to psoriasis treatment and offer interventions to overcome barriers to adherence.

Better adherence can improve outcomes and reduce healthcare costs, authors wrote. Fortunately, there are tools available to help achieve this.

Co-author Steven Feldman, MD, PhD, is a professor of dermatology at Wake Forest University School of Medicine and a globally recognized expert in psoriasis. His exchange with the Reading Room has been edited for length and clarity.

What led you to undertake this review?

Feldman: We were trying to provide a condensed summary that describes the implications of poor adherence, what adherence is like, and some basic ideas for what we can do about it. I have coauthored a that's more comprehensive, but hopefully this review has the basics to complement standard medical education, which focuses more on diagnosis and treatments and less on how to get patients to actually do the treatment.

What are some of the overriding concepts or conclusions in the review?

Feldman: No patient subgroup is very adherent, and this includes patients with psoriasis. However, the most important thing I want to get across is something from the late Buddhist monk Thich Nhat Hanh. I'm paraphrasing, but essentially the saying goes that when the lettuce is not growing well, you don't blame the lettuce.

In other words, clinicians have to take personal responsibility. Nothing I've ever said about a patient's poor adherence should be taken as my blaming the patient. The patient is not using the medicine well. As physicians, we have to take personal responsibility and admit that maybe we didn't do the things that needed to be done to get patients to use their medicine correctly.

Think of a doctor masquerading as a piano teacher: here's a prescription for some sheet music and take it to the sheet music store. I have no idea how much it's going to cost or whether your insurance will pay for it, or how much paperwork you're going to have to go through to get reimbursed. But I want you to practice every day ... and by the way this sheet music may cause rashes, diarrhea, possibly a serious infection. I will meet with you at a recital in 3 months, and if the music doesn't sound good -- which it often doesn't -- I will give you a second musical instrument, and possibly a third, to practice at the same time, because that's what it's going to take for you to sound good.

I mean, it's just a totally ridiculous notion when you think about it in those terms, this idea that you just give people a prescription, tell them to take the medication every day, warn them about side effects, and see them again in 3 months.

The review offers a number of solutions to potentially improve adherence. Are there any on the list that you would like to call out as being particularly effective -- or perhaps one that is overlooked or underused?

Feldman: I've discovered that when I give a patient a prescription, I tell them I need to see them again in 3 days. This works like a miracle, because if you see them 3 days later, it pretty much forces them to fill the prescription right away and to use the medication really well right away. And then they get better.

And then I realized I may not need to see them again right away. I might ask to see them in 3 days but then I stop, reconsider, and say I understand that this would mean missing work and perhaps paying another copay. Instead, I'll give them my cell phone number and ask them to call me in 3 days and tell me how their treatment is working.

This makes patients feel like I care about them -- I care that they don't have another copay, even though it's less money for me. It makes them trust you, and if they trust you, they'll trust the medicine better.

You see technology as a potential ally in this area and describe some technological solutions in the review. Is there a particular technology that interests you for its ability to improve adherence?

Feldman: We were testing teenagers with acne, having them report to us once a week over the internet about how they were doing. It tripled their use of the medicine.

And then I thought, with AI, you could basically give a computer a picture of my face and a recording of my voice, and it can then create an audio-video image of me.

So in theory, whenever I prescribe a new drug in the medical record system, the system would see that a new drug was prescribed and would send the patient a video message of me saying, 'Hey, I'm going to reach out to you in a week and see how you're doing.' And then a week later, my avatar would talk to them, would answer any questions they have. I wouldn't have to be involved at all. For the price of a few electrons, you could create this sense of accountability in people. I would like to test AI for this purpose. I'm testing it mentally right now with the idea of putting together some kind of proposal to do something like this.

Are there any particularly effective methods that clinicians could put into practice right away?

Feldman: I think using anecdotes is great. I can give the patient all the data on the efficacy and safety of a drug, and it's not very convincing.

But if I tell them, 'You remind me of another patient I saw. Their psoriasis was so similar to yours, in fact, I think I saw them in the same room. I think they were sitting in the same chair you're sitting in now. They did really well on drug X. I think that's the right one. I think that's the one we should use too.' That one anecdote, which has no useful information, is more convincing to a patient than all the data.

Anchoring is another powerful tool. If I wanted somebody to take an injection once a month, I tell them they have to take an injection once a day. Then I say, wait... did I just say once a day? Oh God, I'm having a senior moment. You won't have to do it once a day. It's only once a month.

If I start by telling people they have to take a shot once a month, their brain starts comparing the taking of the shot to not taking a shot at all, and they don't want to do it. But accidentally saying once a day first, then once a month, it seems like nothing and they're happy to do it. This is a very powerful tool. It is used ubiquitously outside of medicine. Every time you see a sales price, for the rest of your life you're going to realize, oh, they're manipulating me. That retail price is only there to make me think the sales price is a good price.