How To Manage Patient Expectations

Dr. Cervantes: Obviously, there is a lot of data and clinical experience in dealing with onychomycosis, but I think the key is educating the patient. You can provide the best medications, whether they are topicals or oral drugs, to the patient but if he or she doesn’t know the medication works or doesn’t get involved with the treatment, the treatment will fail.
I definitely believe spending an extra few minutes with the patient will facilitate a better outcome. Patients must understand that onychomycosis is an infection so this is a legitimate threat. We must emphasize the risks and complications of not treating this disease. Perhaps showing some of the available data to the patient will kind of stimulate his or her participation in the treatment of this condition.

We have control of the environment and we can affect the lifestyle of the patient but we have no control of the host. Again we have to educate patients about the condition and let them know there is a high chance of recurrence.
We have been talking about these expectations, the recurrence and the potential side effects of oral antifungal medications. It’s also important to keep in mind that the drugs available now have a very small percentage of cure. For example, according to the package insert for terbinafine, the medication offers a 38 percent complete cure rate.
We must emphasize to the patient that treatment can be a long process. It’s not like a fever. They can’t just take antibiotics or some Tylenol and it will go away. This is a long process and they need to understand why it takes so long. If the patient participates in the treatment and is aware of the recurrence rate, it will facilitate treatment and everybody will be happy.

Presenting Onychomycosis: How To Convince Patients
About Treatment And Compliance
Dr. Mozena: Once we have established that onychomycosis is an infection, we essentially need to educate the patient of the social implications in that it may spread among themselves and to others.
We also need to educate our patients about the treatment plan, whether it’s topical or oral medication, and the need for debridement of the nail. We need to educate our patients to the long-term expectations, the need for constant treatment and then I think we have convinced the patients.
Dr. Malkin: Patient education starts with educating yourself as the physician. You have to buy into what you are trying to sell to the patient. If you believe a hallux valgus repair is in a patient’s best interest, you prepare a balanced presentation but the end result is that the patient has an understanding that your recommended treatment is in his or her best interest, and it may be surgery.

I think the same thing goes with this disease state. Getting back to the tinea pedis-onychomycosis connection, we are not doing our job if we leave out the onychomycosis portion. The claims data says it’s associated with more severe conditions, certainly the secondary infection foot ulcer and gangrene.19
Also, if we feel it is okay to bill for nail debridement every two months, why don’t we think we should be actively treating this disease? I like to call this active treatment. It’s debridement plus oral, debridement plus topical or debridement plus both.
Now what is the patient’s take-home message? Novartis data looked at what takes a patient to “accept infection.”8 When they knew the onychomycosis was an infection that wasn’t going to go away on its own, 59 percent of patients wanted treatment. That’s my take-home message. You have to emphasize that it is an infection and it’s not going to go away. When patients realized the onychomycosis could potentially spread to their fingers or toes, 50 percent said they would accept treatment. When patients were told that the condition could get worse without treatment, 48 percent of them said this was a big driving force to come into the office.8
How do you present this condition? Granted, we initially thought onychomycosis would be a disease of a finite treatment period. Now we recognize that to some extent there is going to be a higher cost in the beginning and a smaller cost later down the line, but the patient should realize that there is some cost associated with it. Essentially, every patient should be given an opportunity for treatment. We owe that to patients. They can decide yes or no but the reality is that every patient deserves a chance at getting some type of a cure, and it’s not up to us to decide this is not a disease worth treating.
Dr. Cervantes: The patient needs to realize that onychomycosis is an infection that needs to be treated, particularly when the patient has a systemic disease such as diabetes.
Dr. Malkin: It’s also important to convey to patients that onychomycosis is not a consequence of aging. It’s an infection.
Dr. Cervantes: If patients are concerned about being on multiple medications, we can give them options that are safe. Combination therapy is the key. In my experience, patients are comfortable with trying an oral medication for one month and using the topical from the beginning with aggressive debridement. Just using the topical medication helps the patient participate in the treatment.
Dr. Malay: It’s also helpful to have some information that you can give patients aside from what you tell them in your office. It may involve giving them a pamphlet on the condition or recommending a Web site they can go to for more information.

Can Clinical Photos Facilitate Patient Education
And Compliance?
Dr. Cervantes: As far as patient expectations and education go, it is a good idea to incorporate a photo of the initial consultation in the treatment plan. That will help the physician as well as the patient in recognizing the improvements of this disease. If the patient comes back in three or four years, you can always pull out the chart, examine the initial condition and compare it to the present condition. Again, it requires participation of the patient as well as the physician to do this.

After we successfully achieve the clinical acceptance of the condition, follow up. If the patient does not have diabetes, follow up every three months and make sure there’s no recurrence because we know it will eventually happen again. Just follow up with patients and always keep them participating in the treatment of their condition.
Dr. Joseph: In regard to the use of photographs, it may scare some of the less technologically excited doctors who may be reading this. Even if you don’t use digital photographs, Polaroid photographs or any sort of photograph, what I have found to be very easy and effective in the past is drawing a little schematic of 10 toenails right on the chart and shading in how much of each nail is involved. It is a very rough drawing but when you see the patients back in three months and six months and a year, you really can see this nail did get better. It also gets the patient excited when you say, “Oh, look, you went from this little drawing with this much nail involvement. Now look how much better your nail is.” Color photographs are nice to have but not everyone can do them. I think the take-home message is getting some sort of graphic or figure involved. It is a good idea.
Dr. Mozena: A lot of people don’t have the capacity for photographs, particularly when it comes to measuring the foot. Sometimes I get out my ruler and measure how much involvement there is, and that’s a good way to quantify it.
Dr. Malay: I find it helpful to have photos on the medical record. When patients go a year or more after achieving a nice result with treatment, they may not see much of a difference at the follow-up visit but you may see recurrence. It helps to show the pictures.
Dr. Malkin: Aside from the Medicare compliance, it’s not a requirement, but if you have photographs, it doesn’t hurt. Having photos might actually help you in a medical review someday.

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