For a successful encounter at an office visit, one needs to be sure that the patient’s key concerns have been directly and specifically solicited and addressed. To be effective, the physician must gain an understanding of the patient’s perspective on his/her illness. Patient concerns can be wide ranging, including fear of hair loss and disfigurement; apprehension of scalp symptoms; distrust of the medical profession or of pharmacologic agents; concern about loss of wholeness, role, status, or independence; denial of reality of medical conditions; grief; and other uniquely personal issues. Patient values, cultures, and preferences need to be explored. Gender is another element that needs to be taken into consideration. Ensuring key issues are verbalized openly is fundamental to effective patient–doctor communication. Appropriate reassurance or pragmatic suggestions to help with problem solving and setting up a structured plan of action may be an important part of the patient care that is required.

In 1992, Cash examined psychological effects of androgenetic alopecia in men and found that although most men regard hair loss to be an unwanted, distressing experience that diminishes their body image, bald men actively cope and generally retain the integrity of their personality functioning (Table 3.1).

Subsequently, Cash compared psychological effects of androgenetic alopecia on women with balding men and found that androgenetic hair loss was clearly a stressful experience for both sexes, but substantially more distressing for women. Relative to control subjects, women with androgenetic alopecia possessed a more negative body image and a pattern of less adaptive functioning (Table 3.2).

Patients’ psychological reactions to hair loss are less related to physicians’ ratings than to patients’ own perceptions of the extent of their hair loss. Even in women with slight hair loss, that loss is imbued with considerable emotional meaning that the physician should not ignore.

Ultimately, androgenetic alopecia is not uniform in its psychological impact. Among men, Cash identified several variables predictive of greater androgenetic alopecia-related distress:

Left to their own resources, individuals with androgenetic alopecia engage in a number of strategies to cope with the unwanted conditions, such as:

Patients who have concluded that the above strategies, or over-the-counter treatments, are insufficient to abate their distress finally consult professionals for medical or surgical solutions.

In 1991, van der Donk et al. conducted a prospective study of the psychological changes in men who received either 2 % topical minoxidil solution or placebo and found favorable changes in psychological adjustment and self-image among responders to topical minoxidil solution compared to placebo recipients, but only in the group aged above 35 years.

In a study of 1,495 men aged 20–40 years who suffered from androgenetic alopecia and were subjected to treatment with 5 % topical minoxidil solution in the setting of two private dermatologic practices, Mapar and Omidian found that almost all the patients gradually avoided continuing the treatment. Only in a few patients was the cessation of medication due to adverse effects. The causes of discontinuation in the majority of patients were the low effect of medication and an aversion to this topical treatment method. The authors concluded that the insignificant cosmetic effect of minoxidil solution caused discontinuity of treatment among almost all patients.

In 2011, a study was performed in Japan by Tsuboi et al. in order to ascertain whether treatment with 1 mg oral finasteride can improve the quality of life of male patients with androgenetic alopecia. Patients aged 19–76 years (average, 33.8) answered Visual Analogue Scale (VAS), Dermatology Life Quality Index (DLQI), WHO/QOL-26, and State-Trait Anxiety Inventory (STAI) questionnaires before and after administration of oral finasteride for 6 months. The changes in these indices before and after treatment were statistically analyzed, and the improved values of the indices in the high treatment responders (excellent or good) and the low treatment responders (moderate or no change) from baseline were compared. There was a statistical difference in the VAS and DLQI indices before and after administration of oral finasteride, while no significant change was found for the WHO/QOL-26 and STAI indices. Interestingly, comparison of high and low responders failed to reveal any statistical difference in the improvement of VAS and DLQI scores. The authors concluded that oral finasteride improves the quality of life of men treating androgenetic alopecia and VAS and DLQI are useful for the evaluation of patients’ quality of life. However, oral finasteride failed to improve the patients’ anxiety, nor did its efficacy correlate with the level of reported anxiety.

Patient understanding and involvement are central to optimal treatment selection and active patient role in treatment. This maximizes patient benefit and safety.

Patient education is more than a simple transfer of information. Printed material, visual and audio aids, and staff trained to interact and educate patients are all helpful. But the physician should also directly review information with patients to confirm the effectiveness of the communication and appropriateness of patient expectations. Such a review also enhances rapport and communicates a sense of caring that fosters trust.

Understanding, emotion, satisfaction, rapport, and empathy are among the factors involved. In talking with a patient, a physician should attempt to learn what the patient expects and help shape those expectations to match the physician’s intention. If the patient forms different expectations than those the physician is attempting to communicate, the physician needs to direct the dialogue to eliminate this expectation gap.

Finally, patients read the unspoken language of physicians: Does the doctor look them in the eye or stare at the computer screen? Is he or she standing up or sitting down when addressing the patient? Does he or she frequently look to the door? If patients are asking the receptionist questions that they should be asking the physician, the doctor needs to find out why. Perhaps a change in body language or improved communication with the patient is needed. To ensure that communication goals are achieved, the physician must also pay attention to the patient’s nonverbal cues. Listening to the patient must be active—acknowledging and encouraging while sharing agreement and disagreement in an empathic manner.

A patient’s hopes and wishful thinking introduce an unconscious dissonance between the patient’s understanding of what the physician says and the patient’s expectation of the outcome.

Patient expectation management is the art of supporting patients in knowing how to be right and when to be satisfied. Managing expectations is a process of creating the structure that is necessary for achieving trust and confidence from the patient and, ultimately, patient satisfaction.

How does a patient develop expectations? Patients learn from a number of sources: from family, friends, and others who have experienced treatment, from conventional news sources, and from Internet sites with information of variable quality, potential bias, and sensationalism. Finally, the patient’s own past experience contributes significantly to future expectations.

Both, the understanding of the patient and his or her values, and the patient’s apprehension of the attending physician as an individual, rather than as a professional, contribute to emotional value. One way to deliver emotional value is to provide information about oneself before meeting the patient: for example, a website and brochure declaring one’s philosophy of care are convenient vehicles for this purpose. Also, public appearance and the social media may be highly effective in directing information to patients. All forms of communication create expectations from patients. Finally, the patient’s understanding depends not only on the material received but also on the way the patient assimilates that information and translates into actionable beliefs, based upon cultural and individual values as well as past experiences.

The Latin maxim tuto, celeriter, et iucunde stands for “safely, swiftly, and gladly” and was originally coined by Asclepiades of Bithynia (124–56 BC), personal physician and near friend of notable personalities of Ancient Rome, such as Cicero and Mark Antony. While the foreign Greek physicians were originally encountered with much distrust by ancient Romans and especially its aristocracy, Asclepiades managed to convince through his high learning, brilliant medical achievements, and worldly wisdom. Above all, he was always attentive and sympathetic to the individual needs of his patients.

Asclepiades was born in Prusa. He travelled much when young and at first settled at Rome as a rhetorician. Though he did not succeed in that profession, he eventually acquired great reputation as a physician. Asclepiades began by vilifying the principles and practices of his predecessors and by asserting that he had discovered a more effective method of treating diseases than had been before known to the world. His remedies were directed to the restoration of harmony. A part of the great popularity which Asclepiades enjoyed depended upon his attending to every need of his patients and indulging their inclinations. Finally, Asclepiades advocated humane treatment of mental disorders. His teachings are surprisingly modern; therefore, Asclepiades is considered to be a pioneer physician in both the medical sciences and psychotherapy.

Also, satisfaction survey questions help create expectations. It is in one’s best interest to distribute and review surveys to patients. At the next team meeting, team members should be asked to complete the patient satisfaction survey themselves as they believe most patients would. When the actual survey results are received, they should be compared with the team’s predicted results to identify expectation gaps and what changes would be needed to improve your scores.

The patient satisfaction survey verbatim responses provide information about how patient expectations are met. One should take the time to review those comments, since they will reinforce the emotional and rational value of one’s care for patients.

Just as providing a checklist for patients is helpful in encouraging follow-through, a checklist for one’s proper practice may also be a valuable prompt for enhanced performance. One should consider developing a checklist to increase adherence to the standards created by the satisfaction surveys.

Asking for feedback is a way to identify gaps. Asking for feedback can satisfy a patient’s need to let one know that something needs improvement. The patient who is given that opportunity may be less likely to vent frustration in an online chat room.

Having patients verbalize their expectations and guiding them should be a part of any communication; a conscious effort will improve effectiveness. With these efforts, a patient is less likely to feel abandoned in any case of perceived failure.

Although testing medical interventions for efficacy had existed since Avicenna (Latinate form of Ibn-Sīnā, Persian polymath regarded as one of the most significant thinkers of the “Islamic Golden Age” and described as the “Father of Early Modern Medicine,” 980–1037), it was only in the twentieth century that this effort evolved to impact almost all fields of healthcare and policy. Evidence-based medicine (EBM), as established by Alvan Feinstein (American physician and mathematician, 1925–2001) and Archie Cochrane (Scottish physician, 1909–1988) in the 1970s, aims at applying the best available evidence to clinical decision making, using techniques from science, engineering, and statistics, such as systematic review of medical literature, meta-analysis, risk–benefit analysis, and randomized controlled trials (RCTs). Ultimately, EBM aims for the ideal that healthcare professionals should make conscientious, explicit, and judicious use of current best evidence in everyday practice.