517 - Acne Treatment, Shared Decision-Making, Celebrating Good Times?

From the Literature

1)  The Best Acne Treatments

When was the last time you checked your knowledge about acne? It is common (just under 10% of the world is afflicted) and costly (about $3 billion in the US). A group of authors recently conducted a network meta-analysis of all acne treatments. As a reminder, a network meta-analysis analyzes multiple controlled studies (even placebo controlled) to determine their relative effectiveness in treating a given condition.

The authors looked for randomized controlled trials of pharmacologic therapies for acne lasting longer than 2 weeks. The studies included people of any age and sex. The major literature databases were searched as were reference lists of included articles. The articles were assessed for quality.

3341 articles were found, and 210 articles (with N = 65,601) were ultimately included. The mean age of the subjects was 20, and they were treated for 12 weeks on average. The groups of interventions included “6 oral antibiotics, 5 topical antibiotics, oral isotretinoin, 5 topical retinoids, 6 combination oral contraception, topical clascoterone, 10 combination therapies, benzoyl peroxide, azelaic acid, and placebo.” The main outcomes assessed were total, inflammatory, and non-inflammatory lesion counts.

Oral isotretinoin was by far the most effective therapy of all, on each outcome, reducing the total number of lesions by 48% on average. Combinations of two and three medications (topical retinoids, topical antibiotics, oral contraceptives, and oral antibiotics) were next most effective (25-36% reduction), and single agent therapies (including topical retinoids, oral antibiotics, and oral contraceptives, and aside from isotretinoin) were least effective (11-21%). Results for inflammatory and non-inflammatory lesions as well as “investigators’ global assessment of improvement” were consistent with these findings. Curiously, some of the newer second-generation topical retinoids (adaplene and tazarotene) did not perform quite as well as the first-generation topical retinoids. There was a significant amount of statistical heterogeneity in the results. Dropouts due to adverse events were <2%.

John’s Comments:

Most of us do not prescribe oral isotretinoin in primary care, because of the teratogenicity concerns and monitoring required. However, there are many other options available, mainly using combinations of therapies, which will allow us to treat a majority of these patients in our practices.

Reference:

•      Huang CY, Chang IJ, Bolick N, et al. Comparative Efficacy of Pharmacological Treatments for Acne Vulgaris: A Network Meta-Analysis of 221 Randomized Controlled Trials. The Annals of Family Medicine. 2023;21(4):358-369. Link

From the Art AND Science of Medicine

2) Engaging Our Patients in “Shared Decision-Making” (SDM)

The process of Shared Decision-Making (SDM) was first described in 1993 by Quill and Suchman as: “The clinician shares information about the illness and treatment options. The patient contributes their expertise about their own goals, attitudes towards risk, and the value they place on various outcomes. Then, combining their perspectives, they can negotiate a solution that is uniquely suited for this patient.”   SDM between clinician and patient and, in some cases, family members, appears to be an excellent strategy for making health care decisions when there is more than one medically reasonable option. The purpose of SDM is to ensure patients:

•  understand their diagnosis,
•  understand that they have a choice about their care,
• understand the risk/benefit tradeoffs involved in each of the choices, and
• come to a decision that is in keeping with their values and preferences.

The bidirectional exchange of information, including information shared by the patient about their values and preferences, is what separates SDM from traditional unidirectional patient education.  Studies have shown that when clinicians try to guess what patients value, they often error in making a “preference misdiagnosis,” which can lead to a plan that an informed patient may not want. 

Framed in this way, theoretically SDM should be used for the majority of medical decisions, since, except in emergencies, there is usually more than one reasonable path.  At the least, SDM should be utilized wherever there is a preference-sensitive decision that has any significant degree of uncertainty. 

The USPSTF has provided a guide as to how one might approach a SDM conversation for various recommendations based on the strength of the recommendation, and therefore, also the level of uncertainty.   

This practice can be facilitated using a decision aid when one is available. 

Mark’s Comments: 

I continue to be concerned about how the term “shared decision-making” is being utilized by many professional groups as a ubiquitous “catch-all phrase” that implies it is a globally understood and easily accomplished process.  It is not.  Indeed, both the literature and the realities of clinical medicine would indicate is more aspirational than based in clinical reality.  We know how those conversations usually go: “You’re due for your ___ and your ___ AND your ___ ….” 

Understood as the 4 steps listed above, there are many challenges to this process. What does it mean for a patient to “understand” a diagnosis?  Can most patients truly understand the nuances of possible benefits and risks of different paths when these are often hard to quantify for a population, let alone for an individual patient, and where we in medicine often can’t even agree (e.g.: HTN guidelines, PCa screening, T2D goals, breast cancer screening, cancer treatment, etc.)?  What if their values are in conflict with sound medical practice or societal values (opioids, antibiotics, etc.)?

Additionally, true “academically-defined” shared decision-making takes time – sometimes a lot of time depending on the decision.  The "Ottawa Personal Decision Guide Aid" demonstrates just how detailed “true” shared decision-making could be.  And what about all the data indicating that most people (and many clinicians) do not truly grasp statistical probabilities, often greatly overestimating potential benefit and underestimating potential harm, and how easily we can influence patient decisions based on our own biases?

Instead, acknowledging the limitations and uncertainty involved in patient care, let’s use the 4 steps above as an “aspirational” general guide rather than a hard-and-fast but realistically impractical rule for all patients in most circumstances, doing our best to ensure that they are routinely informed about and included in decisions about their care. That just seems like the right thing to do.  Perhaps AI can help us overcome some of the present limitations in implementing a more robust process.  Time will tell.

References (last 2 are examples of structured SDM approaches)     

• US Preventive Services Task Force.  Collaboration and Shared Decision-Making Between Patients and Clinicians in Preventive Health Care Decisions and USPSTF Recommendations.  JAMA. 2022;327(12):1171-1176. Link        
• Massachusetts General Hospital Health Decisions Sciences Center.  Shared Decision Making Process Survey.  2016.  Link        
•  AHRQ – The SHARE Approach to Shared Decision-Making.  April 2016: Link

From PeerRxMed ( www.PeerRxMed.org )

3) Celebrate Good Times (with others)?  Come On!

“Celebration is habit fertilizer.”  BJ Fogg, PhD, author of “Tiny Habits: The Small Habits That Change Everything”

There’s a guy at the local gym where I’m a member who always uses the treadmill closest to the door when it is available.  As others go by to leave, he smiles, holds out his fist for a “bump” and says, “You did it!”  Invariably, the bump is reciprocated, and that small gesture of celebration brings a smile and some well-wishes for the remainder of the day.

In full disclosure, I’m “that guy.”  Over time, I have gotten to know most of the gym “regulars,” and they now look for this exchange as part of their workout ritual.  Why do I do this?  For me, encouraging others is a form of celebration and anyone who comes to the gym to take care of their health deserves to be celebrated.  But, of course, I don’t do this just at the gym.  I look for similar opportunities to connect in this way throughout my day as I celebrate small moments of goodness with patients, colleagues, and friends.

It turns out, these “little gestures” are not so little.  Psychologist BJ Fogg is the founder and director of the Behavior Design Lab at Stanford University, and in his research has found that adults rarely celebrate their successes or feel good about their accomplishments.  Rather, they focus mainly on shortcomings, and there is a significant cost to that.  He writes, “Celebration is the best way to use emotions and create a positive feeling that wires in new habits …. When I teach people about human behavior, I boil it down to three words: Emotions create habits.  Not repetition.  Not frequency.  Not fairy dust.  Emotions. When you are designing for habit formation — for yourself or for someone else — you are really designing for emotions.”

Indeed, it’s tapping into the power of our emotions, not the mechanics, that is the not so secret but greatly underutilized “secret sauce” for making improvements in our lives.  This doesn’t discount the importance of having a well-thought-out plan, but without a deeply held, inspiring and motivating “why” and teammates who are cheering you on along the way (and you, them), long-term success is much less likely.   And while a “private celebration” of these small victories is better than none at all, it seems much wiser to take advantage of our evolutionarily wired interconnectedness and invite others into the “winners circle” with you.  This is what “that guy” at the gym is doing – and it works, day after day, one fist bump and smile at a time.

This week, find at least one “fist bump opportunity” and take the time to connect and celebrate with a colleague or teammate, even if it is just for a moment.  But be careful!  You might turn out to be contagious.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org