FlakeHQ Interviews:

Dr. Steven Feldman

Dermatologist, Professor, Founder of DrScore.com

Interviewed by Ed Dewke
in April, 2005

ED: Dermatologist Steven Feldman is known by name to most people who belong to the National Psoriasis Foundation (NPF) and read their literature or attend their conferences. In many respects, Dr. Feldman is the “derm we’re always looking for.”

I would wager that at least 30% of the flakers who are seriously bothered by their P have had occasion to curse their derm. (I base that on 10 years of correspondence at FlakeHQ.) The biggest complaints — in this order — have been:

I have long waits and short visits with my derm.

My derm acts unsympathetic to my misery.

I think I know more about P and P treatments than my derm does.

Not only is Dr. Feldman well aware of these complaints, he has established a web site where patients can “score” their doctors and where doctors can arrange customer satisfaction surveys — DrScore.com.

Dr. Feldman holds a PhD as well as an MD and he is a faculty member at Wake Forest University School of Medicine. Here’s his full title: Steven R. Feldman, MD, PhD, Professor of Dermatology, Pathology and Public Health Sciences; Director, Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

He is a member of the Medical Board of the NPF and chairs that board’s Subcommittee on Education. He also serves as the Director of the Foundation’s Chief Resident’s Meeting on psoriasis treatment.
My interview with Dr. Feldman was conducted through April, 2005, via email. -Ed

ED: What is the relationship between psoriasis and psoriatic arthritis? Is it one disease with two manifestations, or is it two separate diseases?

Feldman: This is a tough question. We don't even know if psoriasis itself is "one disease" or one rash caused by a multiplicity of different genetic and environmental risk factors. The way I currently think about it is that psoriasis is a condition in which the immune system is causing inflammation, and that inflammation can be in the skin, in the joints, or in a combination of the two. I don't know what makes the immune system in psoriasis go haywire in the first place, much less what makes it flare at times, or go to the skin versus the joints. Sorry I can't be more helpful here!

ED: At an NPF annual conference several years ago, I heard you say that a significant problem derms have in treating psoriasis is patient non-compliance. What did you mean by that?

Feldman: Psoriasis is a long term, frustrating disease, and just taking or applying the treatment is frustrating, too. Over time, people use the treatment less and less, if nothing else because they get tired of it. Many of the treatments have annoying or worse side effects that may limit people's use. Other people are simply afraid of the risks and don't use the medication. All that is understandable. All too often, though, patients are a little sheepish about telling their doctors they aren't using the medication. Heck, I don't mind if my patients don't use it, but I'd just like to know.

We actually did a clinical trial where we measured subjects' use of a topical treatment using an electronic monitor in the medication bottle cap. We had them fill out a diary of when they applied the medication. According to the diaries, they said they used the medication twice a day just as they were supposed to in the study. According to the electronic monitors, they didn't do nearly that well, missing doses regularly.

It's a problem for several reasons. First, there's the risk we'd move to something more strong/risky than necessary. Second, the doctor needs to know what the patient can realistically do.

I have a feeling that if we tell patients to use the treatment for just one week, they'd get a better result than if we told them use it for eight weeks. I think that because it's much harder psychologically to face putting something on for eight weeks versus one week. If patients did a great job using the medication the first week, they'd probably see some good, encouraging results, and would continue using the medication into the future.

ED: What do you say to patients who want to try alternative approaches to treatment?

Feldman: I say go for it, as long as it is safe. If you want to try some diet — like quitting tomatoes or pork/other meat or gluten — I certainly don't mind. I think it's good to get a well balanced healthy diet, regular exercise, healthy weight, quit smoking, etc. I assume that will help one's general health and wouldn't hurt the psoriasis. As far as I can tell, no scientific study of any dietary intervention has ever found that intervention to help psoriasis. I'd go a little further to say that no scientific study of any alternative treatment has ever shown efficacy for psoriasis, either. Of course, if it had, I wouldn't call it an "alternative" treatment.

One of the things I have great confidence in is prescription medications. The FDA regulates these medicines like a hawk. You can't change the color of the label without getting the FDA's permission. For better or worse, these medications are very well tested and understood. Now when one goes to an "alternative" medicine, maybe some herb shipped in from China or something, one doesn't have any of those assurances of what's in the product. The so-called herbal treatment might have been adulterated with some powerful medication (e.g. the Skin-Cap story: a supposed zinc pyrithione product that was later found to contain the powerful steroid clobetasol), and one would never know.

Some people consider sun lamp treatments "alternative." I think tanning beds can be a standard treatment for many patients with psoriasis, especially if they can't get office UV treatments conveniently. I'd encourage patients to be followed by a dermatologist if they choose that route as I think there probably is some small increased risk of skin cancer and other tanning bed side effects.

ED: If you agree that psoriasis is a chronic disease, do you consider biologic medicines a probable long-term treatment course (akin to type 1 diabetics taking insulin every day of their lives)?

Feldman: Psoriasis is usually chronic, but it is also unpredictable. For some patients, it seems to come in series of cycles of flares and remissions. For these patients, it may be possible to use phototherapy, traditional systemic treatments or even biologics for a short period of time to control the flare, then taper off the treatment.

Some dermatologists advocate various rotation regimens. I think it is best to use the safest treatment that works and to stick with it. If you do that, I don't see the need to switch as it would entail switching to something safer that didn't work or to something riskier. So unless the drug has definite long term cumulative toxicity, I say stay the course.

Now methotrexate can have long term cumulative risk to the liver, but we can monitor for that. Biologics, as yet, have no known cumulative risk. The two treatments that do have a lot of cumulative risk are cyclosporine and PUVA.

I like the idea of short courses of cyclosporine, but not long term maintenance because of the high risk of kidney toxicity when the drug is used for more than a year or 2. Still, if it is the safest drug that works for a particular patient, even then one might continue it beyond the usual time frame, albeit with careful monitoring.

Lots of PUVA can predispose to skin cancer, particularly in people with fair skin color, and because that risk can increase with subsequent immune suppression (and since we're getting access to all these great new immune modulating treatments like biologics), I recommend PUVA a lot less than I used to.

Of these, I think phototherapy has the best safety profile. Biologics seem pretty safe for long term use as far as we can tell, but they haven't been around long enough for us to fully know the long term risks.

ED: At FlakeHQ and on the discussion board PsorChat we're reading anecdotal reports about the biologics "wearing out" after some period of success. Of course, people who have tried many treatments for their psoriasis may be used to this; but we'd hoped the biologics would be different. Are you seeing evidence that the biologics may quit working over time?

Feldman: It's really hard to know whether the patient is just getting tired of using the medication and starts missing doses, if the disease is just worse independent of the treatment or if the treatment is just not working anymore. Psoriasis is consistently unpredictable. I think we can expect the disease to get better and worse in some people despite whatever treatments we offer.

ED: One of the most frequent complaints at FlakeHQ is about expensive consultations with long waiting time, doctors who spend no more than ten minutes with the patient and never ask to see a lesion that isn't readily visible. Is this to be expected? If so, what’s going on that’s not obvious but appropriate?

Feldman: I'm developing a growing appreciation for the general issues that revolve around providing excellent medical care. Dermatologists are extraordinarily good at diagnosing and managing skin disease. From across the room I can probably tell psoriasis when I see it, and I can probably write the correct prescription (most of the time) as I'm walking toward the patient. I'm not saying that's good medical care, though.

To effectively care for patients with psoriasis, I think I should start by sitting down, talking with the patient, touching/examining the psoriasis lesions, and involving the patient in planning how to best treat their psoriasis. Like most doctors, I love spending time learning about how the patient feels about their condition, answering their questions about it, and working with them on a good treatment plan. Sometimes, though, there are so many patients to see that I don't seem to be able to give everyone as much time as they — or I — would like.

Should patients expect to get too little time from their doctor? No. Some doctors do a fabulous job of spending time with their patients. I know my internist does! I think sometimes I exceed my patients' expectations of the time I spend with them. Other times, I know I seemed rushed — there are more patients with psoriasis who want to see me than there is time to see me. I think there needs to be more dermatologists. I think we need to do a better job using physician extenders [Physician's Assistants (PAs) and Nurse Practioners (NPs)]. I think part of the problem is not just the amount of time but also how we use it. There's too much wasted on insurance issues.

I heard a terrific lecture on medical excellence given by a dermatologist (Dr. Victor Marks). He likens health care to other "service" industries. Other service businesses compete with each other and make efforts to exceed their customers' expectations. I just had terrific service on a family vacation trip to Sea World and at a business meeting trip to a Washington, D.C., hotel. Shouldn't physicians try to give service excellence, too? I think so. The time spent with the doctor is just one aspect of this.

One of the ways other service industries work toward excellence is to get feedback from customers. Wouldn't it be great for physicians to regularly get feedback from their patients about whether patients feel like they are getting enough time? I've been working on a separate project — www.DrScore.com — that would empower patients to give this kind of feedback to their doctors (and also empower doctors to get that kind of feedback easily and inexpensively).

ED: DrScore.com is a web site where anyone can go, look up their doctor, and respond to a satisfaction survey about that doctor and his or her practice. They can also look up rating averages others have given doctors. It’s all free to patients. And by using DrScore doctors can get their own on-line customer satisfaction investigation. How have your colleague doctors responded to DrScore.com? What are your hopes for this venture in the near and long term? Has there ever been anything similar?

Feldman: So far colleagues have been luke-warm positive to the idea. They certainly haven't hated it. Doctors work extremely hard to provide the best possible care. They study in medical school for four years after college, dermatologists then do four years of residency, then you have to do continuing medical education for the rest of your career to keep up with what's new. Doctors are pretty confident they provide good medical care, so I don't think that part worries them. And there's nothing that makes a doctor feel worse than an unhappy patient — heck, we became doctors because we wanted to make people feel better.

Something that helps doctors make their practice work better is a good thing. Doctors are a little scared of adding anything because their costs, regulations and paperwork are hellaceous and worsening all the time. When they find out that DrScore lets them get high quality, detailed patient satisfaction information without any hassles and at a very, very low cost, some doctors are actually very excited about using the service. Some think it is a great way to learn more about how their office is functioning and how their staff (including PAs and NPs) are doing.

In the short term, I hope I can get people who are interested in healthcare to use the service and get it going. We need to start with a good base of scores to use as benchmarks. I'd like to see some more doctors start using the service so they can share how much it helps them with the rest of the medical community. In the long term my hopes are that most U.S. doctors will begin using the service and will begin to post the results in the office for they and their staff to follow. When you look at a graph and see where your patients are less than completely satisfied, you quickly work to fix it and get a lot of positive feeling from seeing those graphs move toward greater excellence. Plus, DrScore will show doctors how their practice compares to other doctors' offices.

Doctors can use the findings to give positive reinforcement to the staff that are doing great. They may even use the information in their negotiations with insurers. Hopefully giving patients this way to let the doctor know what's right and what can be better will eventually help doctors reduce their malpractice risks and costs.

Another goal for DrScore is to educate patients. See, if patients come to the site and look for a dermatologist, I know they probably have a skin disease. So the site gives them information about the NPF, the eczema foundation, the AAD and the National Library of Medicine web site on skin diseases. Hopefully DrScore will help doctors enhance the care they offer, will help empower people to be better patients, and will even help grow and strengthen patient advocacy groups!

There are other patient satisfaction survey services that doctors can purchase, but they cost a lot more and are typically quite a hassle for patients and the office staff. There are also some Internet sites that will sell patients information on doctors, but I'm not sure they have the kind of info that patients want most and the reports aren't free. DrScore is completely free to patients and always will be.

ED: A PA (Physician's Assistant) has taken over my routine consultations at the dermatologist's office. It's not unusual for me to go over a year without seeing my dermatologist. I have complete confidence in my PA and, in fact, enjoy the longer, more conversant sessions that have resulted. Is this just my derm's practice or is this becoming more common?

Feldman: The use of PAs is growing rapidly in dermatology. In fact PAs are used more in dermatology than any other specialty except maybe orthopedics and ophthalmology. They are capable of doing a lot of medical care, and personally I've had TERRIFIC experiences working with PAs. When there aren't enough dermatologists around to see all the people who have skin disease, PAs can be a great way for a dermatologist to extend their ability to care for the population.

ED: You are also a teacher at Wake Forest University School of Medicine, and I'm sure, to the degree you are able, any future dermatologists who come under your wing will graduate with a well-rounded knowledge of psoriasis. But do you think this is typical of the kind of education about psoriasis dermatology students in general receive? What advice would you give for psoriatics looking for a new derm? For example, pick an older derm who has many patients with psoriasis or a younger (more recently educated) derm?

Feldman: Derms and patients are both people with distinct personalities, and I think you just have to find one that fits what you are looking for (though hopefully when patients start giving doctors feedback through DrScore, doctors who aren't meeting their patients expectations 110% will learn what they need to do to achieve that goal).

Many older derms are as on top or more on top of new developments as the youngest derms. I like the idea of seeing someone with a lot of experience. Still, dermatology is about the hardest specialty there is to get into, so if you see a young dermatologist, you can be pretty sure that not only did they do well in college to get into medical school, but they probably were near the very top of their medical school class to have gotten that coveted dermatology residency position. The Psoriasis Foundation is working to make sure these residents get a great psoriasis education by holding an annual psoriasis education meeting for the chief residents at different programs. The Foundation has had grants that covers the cost of the residents’ attendance. The meeting has had great feedback from residents about what a terrific learning experience it has been.

As far as picking a derm is concerned, if you live in an area with a lot of choice, it probably wouldn't hurt to go to the NPF website and look to see if the derm has registered and offers many different psoriasis treatment options. If they do, then you've probably found a derm with considerable interest and experience with psoriasis treatment. Hopefully, as more people go to the DrScore website and give doctors feedback, DrScore will become a terrific resource to help people find a highly rated physician.

ED: What do you say to patients whom you diagnose with psoriasis for the first time?

Feldman: Number 1, I try to tell them I'm a good doctor, so they'll trust me and follow my advice. I tell them this by listening to them, touching/examining their lesions, and letting them know I will work with them to find a way to control the disease. Second, I urge them to join the National Psoriasis Foundation. The Foundation is a great way to learn about what's known (and what's not known) about psoriasis and its treatment and to become active toward finding a cure. Then we decide if they have localized psoriasis that needs topicals or generalized psoriasis that needs photo/systemic treatment. Localized means the patient is happy putting topicals on all the spots. If they are, we treat with topical steroids, maybe some Dovonex, too. If they have more generalized disease, we recommend UV treatments first (unless there's a lot of arthritis that requires systemic drugs), sometimes with Soriatane. If that won't work for the patient, then we discuss the pro's/cons of methotrexate, Amevive, Enbrel and Raptiva. We try to find the one that's right for the patient, which isn't always easy.

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Be sure and visit http://www.drscore.com.

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