Dermatology Online Journal

Looking beyond the borders of our specialty: The 2006 Clarence S. Livingood MD Lecture
Steven R Feldman MD PhD
Dermatology Online Journal 13 (4): 20

Center for Dermatology Research, Departments of Dermatology, Pathology and Public Health Sciences; Wake Forest University School of Medicine; Winston-Salem, North Carolina

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Abstract

The following is adapted from the Clarence S. Livingood Lecture delivered at the 2006 American Academy of Dermatology Annual Meeting. The Livingood Lecture is the only presentation during the Annual Meeting of the American Academy of Dermatology that is specifically dedicated to issues other than the science and practice of dermatology. The lecture describes the impact of the compartmentalization of Medicine. Compartments prevent us from seeing certain things and make some of our own observations untrustworthy. Furthermore, compartments affect the context in which we interpret our observations. These limitations on perception impact the physician-patient relationship and outcomes of care, as well as inter-specialty relationships. Compartments may even play a critical role in world conflicts. We would be wise to follow Dr. Livingood's advice to look beyond the borders in our lives.

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"I had the feeling that it was very important that dermatologists not be insular, that we look beyond the borders of our own specialties..." Clarence Livingood, MD [1].

Giving the Clarence S. Livingood Lecture is a great honor. I didn't know Dr. Livingood personally and tried to learn about him through his Medline-referenced publications, but one can't fully appreciate Dr. Livingood that way. I found out more about Dr. Livingood by talking to his friends and colleagues, the many dermatologists who have known him well throughout his career and life. They told me what a great politician he was and what a tremendous impact he had on our specialty. For example, dermatologists probably wouldn't have the opportunity to have board certification in dermatopathology if it hadn't been for Dr. Livingood's ability to bring together a consensus, not just within dermatology, but also among other specialties. Livingood wrote that dermatology is a small specialty and that we need to look beyond our borders and integrate with the rest of Medicine [1]. The impact of borders is the theme of this lecture.

Compartmentalization in medicine

The field of medicine, much like the rest of life, is compartmentalized. This compartmentalization has a significant impact on our view of the world and must be considered in our day-to-day interactions. Compartments create borders, and all of us, at one time or another, have trouble seeing beyond them. There are important things happening in other compartments that we can't see. There may be bias in what we see coming from another compartment, so we can't always trust even what we do see. There are also indirect effects of compartmentalization. Compartments can profoundly affect the context within which we view reality. The implications of borders are so profound that some of the things in this lecture will sound so at odds with our perceptions as to seem absurd, heretical, and maybe even dangerous. I hope that one or more of the examples we'll cover will challenge your current beliefs. If they do, I hope you will carefully consider the possibility that your current thinking may be based on an effect of compartments.

Things we can't see

We start with things that we can't see. In dermatology we give patients prescriptions. When a patient returns not doing well, we may have the perception that our medications did not work. But we can't see whether that patient used the medications we prescribed.

There are now electronic monitors that allow us to objectively record use of medication. We used these electronic monitors in a clinical trial in which 6 percent salicylic acid was given for psoriasis [2]. We told subjects to apply the medication twice a day for 8 weeks. We informed the subjects that we would monitor their use of the medication and asked them to complete a log of medication use and to bring the medication back for us to weigh. We didn't lie to the subjects; we just didn't mention the computer chip in the medication cap. Subjects across the board self-reported a near 100 percent adherence rate for the entire 8-week study. However, the electronic monitor recorded this rate of usage only for the first day of the study; compliance decreased by 40 percent over the first few days, and continued to progressively decrease through the 8 weeks of the study (Fig. 1). The rate of decrease was about 20 percent every 5 weeks. If we could extrapolate beyond the end of this study, compliance would go down to zero in about 25 weeks. Thus, at about 6 months, one would expect patient compliance to go to zero. In dermatology, we call this trend tachyphylaxis [3].

Many of us were probably taught by great teachers of dermatology that tachyphylaxis to topical steroids was "the more you use the steroid the less it works." But that belief was based on the erroneous assumption that patients use medications the way we prescribe them. The truth, however, is that tachyphylaxis is "the less you use the steroid the less it works"; patients get tired of putting topicals on their chronic skin disease day in and day out. Eventually, they stop applying medication, which leads to tachyphylaxis. Our teachers, great as they were, were most likely plain wrong about the mechanism underlying this basic principle of dermatology because they couldn't see what was happening in the patient's compartment.

Things we can see but can't trust

Things we can't see are, of course, very important. But what about the things we do see? We rely on our own observations for judgments about the world. Because of compartmentalization, there are things we can see that should not be trusted. Office phototherapy is a very effective psoriasis treatment. Let's assume for a moment that office phototherapy clears 80 percent of patients with psoriasis. If we treat ten patients in our office, eight of these patients will clear. Indoor tanning is another form of ultraviolet light, but many dermatologists don't think tanning clears psoriasis. Let's just assume for a moment that tanning is as effective as office-based light treatment, that it would clear eight out of ten patients (this is just hypothetical! The actual efficacy of tanning for psoriasis is not that well defined [4, 5]). Let's say a dermatologist sees ten people who came in after trying a tanning bed for psoriasis. How many of them would be clear? At face value, the answer appears to be eight; but, in actuality, none of those ten would be clear. People whose psoriasis cleared with tanning would not come in to see a dermatologist. The dermatologist would only see patients whose disease did not clear; relying on observations, that dermatologist would get a very wrong sense of the actual efficacy of tanning for psoriasis.

This type of bias has dramatic effects on the way people view the world, especially in terms of human relationships. Doctors are fabulous in treating patients; we take care of thousands and thousands of people, and nearly all our patients do great. The news media, however, is only going to report the 1 time in 10,000 that there is a serious problem, and the public is going to receive a warped impression of American medicine. If you wanted to understand the quality of medical care (or anything else) in the U.S., you wouldn't want to judge it solely on the events that newspapers report! You'd need to get in there and assess a more representative sample.

This type of bias has dramatic impact for inter-specialty relationships. Dr. Livingood understood this very well when he said that we need to look beyond the border of our specialty and integrate dermatology among other specialties. Although all doctors go to medical school together, they eventually separate into different specialty group compartments. And the impact of this compartmentalization colors how different specialties view each other.

Consider this simple example: how many dermatologists in the US have ever seen a patient for a skin disease that had been effectively managed by the patient's family physician? None. No dermatologist has ever seen that and no dermatologist ever could. Only treatment failures are referred to a dermatologist, a simple fact that makes it too easy for us to believe that family physicians do not effectively manage their skin disease patients.

This kind of bias also affects how other specialties view us. When otolaryngologists see a patient who had a squamous cell carcinoma treated by Mohs surgery, it is almost surely because that tumor metastasized to regional nodes. Otolaryngologists may see that nine out of ten squamous cell carcinomas they excise are cured. But even if Mohs micrographic surgery done by a dermatologist cures 999 out of 1,000 tumors, the otolaryngologist will see in referral only the 1 in 1,000 that metastasized before the primary tumor was removed. Based on such observations, some otolaryngologists might be led to believe that Mohs micrographic surgery causes squamous cell carcinomas to metastasize. One can see how surgeons could get a warped view of the care that dermatologists provide.

This type of bias creeps into many common issues facing dermatologists. There is currently a debate about the role physician assistants (PA) should play in dermatology. It is very easy to see how dermatologists who work with a PA would have a very different impression of the quality of care the PA offers compared to the impression of dermatologists who don't work with a PA. The dermatologist who doesn't work with a PA will see only a PA's failures, never their successes.

This type of selection bias goes beyond our professional lives and affects how we see the world around us. Consider how Muslims are viewed in a post-9/11 US. The American media regularly reports on episodes of suicide bombings in the Middle East; and based on those reports, Americans probably get the sense that Islam is a violent religion. Yet the word "Islam" comes from the word "peace." If there are a billion Muslims in the world, the suicide bombers seen in our media probably represent no more than 1/10,000th of 1 percent of all Muslims. Is this a representative sample of Muslim behavior? Certainly not. The United States is a truly great country in so many ways, but I wonder what view another culture would have of the US. if they only read about us in the newspapers. Would they perceive a culture dominated by the murderers, anorexics, and crooked businessmen who make our news? We should be very cautious in how we interpret our observations of other peoples. If we view them at a distance, we run a considerable risk of seeing a very unrepresentative picture of them.

Indirect effects of compartments: Context

These direct effects of compartments are pervasive and important. Indirect effects of compartments may be even more important. Within a compartment there is a shared context that we bring to our view of the world. The effects of context on the realities we perceive are powerful. insidious and well-illustrated by visual illusions (Fig. 2). Consider the blue color of the veins of the flexor wrist. We know that venous blood is red, yet the veins appear blue. If we have a computer objectively determine the color of the vein from a digital photo, we find the vein is actually a shade of pink (Fig. 3a). Seeing that same pink color on the background color of the surrounding skin causes the blue appearance (Figs. 3a and 3b). Context has profound effects on our perceptions of reality. The effect of context is not limited to color perceptions; the effect of context is built into the way our brains function and affects every truth that we hold.

Context affects what our patients perceive. Our patients didn't go to medical school; they don't know if the prescriptions we give them are any good or not. They don't know if their surgery was done well. They do, however, have a perception of the quality of their care and that perception is driven by the context of their visits. If a physician's office is efficient and well-maintained and everything that the patient perceives about the experience engenders patient satisfaction and confidence, the patient is going to perceive that the medical care was excellent [6]. However, if the patient sees an unkempt waiting room or if she feels the medical staff is uncaring, the context of her visit is apt to negatively affect her perception of the quality of her care. If patients see a sign about how they have to pay their co-payment at the time of visit before they see anything about the care we provide, they are apt to think we're more interested in their money than their medical needs. We need to carefully consider how context affects how our patients perceive us.

My clinical specialty is psoriasis care. When treating psoriasis patients, it is critical to project empathy [7]. Palpating the lesions communicates both that a careful examination was done and that the patient is not untouchable. Asking a few questions such as: "You've probably found the topical treatments you've tried before very frustrating, haven't you?" communicates that you understand their concerns, as well as their disease. Encourage patients to join the National Psoriasis Foundation. The Foundation helps address the many psychosocial questions our patients have. While doing these things may not change the prescription you write, it may have considerable effect on whether patients trust you and whether they will follow your instructions and use what you prescribe.

Context also affects doctors' thinking. One of the biggest conflicts facing dermatology today is regulation of office surgery. We may have the impression that greedy surgeons and anesthesiologists are out to get us by regulating what we can do in our offices or by requiring hospital privileges to do surgery in the office. The truth, however, is that they may not be thinking about us at all. More likely, they are thinking of the surgeon or anesthesiologist who practices while intoxicated, then loses their hospital privileges. These concerned physicians want to ensure that doctors who lose hospital privileges are not allowed to continue their practice in the office setting. Surgeons and anesthesiologists may view things from a completely different view point than we have; they certainly don't see this as an issue of "protecting our turf". This is not to say there aren't underlying economic motivations affecting their perceptions. They have those motivations, and we have them, too. Consciously, however, these surgeons and anesthesiologists may not be thinking about protecting turf any more than we are. We need to have open dialog with our colleagues and learn how they see things in order to fully understand them and work together for the benefit of our patients. This was the lesson that Dr. Livingood shared with us.

The vast majority of what is seen as "good" or "evil" is affected by context. The cartoons we watch growing up condition us to believe in pure evil, that there are bad guys out there who do bad things. But most of the time there is no pure good and there is no pure evil; there are simply perceptions of reality that are colored by context. Consider some examples. Are health insurers evil? It may seem that way to us sometimes. But many insurers probably feel that they are in the business of helping patients pay for medical care; they don't go home at night thinking they are evil. And they probably think that doctors care less about patients and more about reimbursement. Similarly, pharmaceutical companies seem to be considered evil in the public eye. Yet these companies create, discover and develop the drugs that actually improve our patients' lives.

It all depends on your perspective

When we dermatologists look at the new US government program to regulate isotretinoin use (the iPLEDGE program)[8], we see things in the context of severe acne patients that desperately need isotretinoin. Others see it from the context that birth defects are about the worst thing that could possibly happen. Assume for the moment that the iPLEDGE program requires an hour wait on the phone. Dermatologists would probably perceive this as an unacceptable burden on providing needed care to someone with scarring acne. Someone who had a child with birth defects, however, might think an hour wait is entirely reasonable to help prevent a birth defect.

There is one objective reality—an hour wait on the phone. How people interpret that reality will depend on their different contexts. If we try to reduce barriers to using isotretinoin without recognizing and addressing people's specific concerns for preventing birth defects, we are not likely to achieve much headway. If others try to make it even harder to prescribe isotretinoin, we would surely fight that for the benefit of our patients. Achieving a consensus on what to do requires that each side consider and understand how the other views the issue.

Implications for conflict in the world

When invited to give this lecture I was told that it is the only presentation during the Annual Meeting of the American Academy of Dermatology that is specifically dedicated to issues other than the science and practice of dermatology. So far, you're probably thinking that this lecture has everything to do with the practice of dermatology. In some ways it does. However, what I have presented so far are basic principles that apply beyond dermatology. I will take the liberty of describing how these principles apply to arguably the most pressing issue facing dermatologists and everyone else today, world conflict.

First, let's review these principles. We've learned that because of borders, there are things we cannot see. We've learned that our mentors may have been very wrong about even basic, time-honored concepts because there were things they did not see. We've also learned that we cannot trust even the things that we personally observe because they may not be representative of the full reality. Finally, we've discussed how our minds' interpretations of observations can be affected by the contexts of our lives. We've seen how different people can look at one objective reality and draw two completely opposite conclusions.

Today, U.S. dermatologists see their country at war in Iraq and with elements of the Islamic world. Are differences in context and perception at play here, too? Our world is compartmentalized by countries and by religions and there is little communication between the Muslim and Western worlds. There is much we do not see of each other, and the little we do see may be a very biased sample. How we interpret events are dramatically affected by the contexts of our lives.

I grew up in a tight-knit Jewish community and went to Hebrew school for primary education. What little I knew of Arabs was that they were at war with Israel. My family was touched by what happened to Jews in Europe during World War II. Within that context, I didn't understand why there was a Palestinian problem. The Jewish State seemed just and necessary; it seemed Palestinians forced to resettle by the creation of the Jewish State could go anywhere else among the nations of the Arab world. Had I grown up in the Arab world, however, I probably would have had a very different view. I might think that Palestinians had been violently expelled from their own homes and ought to be allowed to return. I might see the West as arrogant and lacking in respect for my people and my traditions; I might also wonder what motivated the West to put a Jewish state composed predominately of European people right in the middle of the Arab world. The context of history—of the Crusades and of colonialism—might also affect my perceptions.

Consider the quote, "The contrast couldn't be clearer between the hearts of those who care about human rights and human liberty and those who kill. The war on terror goes on." This was said by President Bush. Wouldn't a Palestinian refugee use the very same words to describe how they are treated by Israel? Killing is an objective reality, whether it is done with an F-16 or with a suicide bomb, and while many will object vociferously to my saying this, terrorism and retaliation are words that in large part depend on the context in which one views the killing.

We ought to question whether our teachers were right in what they taught us about Arabs and other Muslims. We ought to question whether we have a truly representative view of Islam and of Muslim people. We ought to consider how the Arab world views our country's actions, knowing that they will interpret our actions from their context, not from ours. This is not the time to assume that our current way of looking at things is the right way or the only way to look at them. In this time of war, we must consider our own context and the context from which the other side views things if we seriously want to engage in meaningful communication. We have an opportunity to begin that communication for ourselves within the international dermatology community. It will be a challenging conversation. We will need to be open to the possibility of changing views that we hold passionately.

Conclusions

Specialization improves the delivery of medical care in many ways, but it also results in the compartmentalization of Medicine. Compartments exert powerful influences over our views of the world. We are not going to be fully successful with our patients or our colleagues unless we attempt to see and understand their points of view. Considering how our patients view us could actually result in better treatment outcomes and lower our malpractice risks [9, 10]. Dr. Livingood understood that we should be better integrated with our colleagues; to do so would reduce the mistrust that compartmentalization engenders. Though it may appear otherwise to us at times, we shouldn't forget that all medical specialties are similar in holding patients' interests at heart.

Remember there are things that we don't see. Let's be on the lookout for them. For those things that we do see, be aware that we may not be looking at a representative sample. Finally, consider how the appearance of things is based on the context that we bring to the situation. I hope the examples of the dramatic affect of compartmentalization on our interpretations of observations in our professional lives will open us to consider that miscommunication and differences in interpretation of observations lie at the heart of even some of the most horrific conflicts in the world today. Yes, this probably challenges many of our passionate beliefs. Our initial reactions will surely be to argue we are right based on our current conceptions of the world. Take a moment, though, to consider how the world looks to others and how context affects both our beliefs and theirs. Consider the possibility that, though it appears otherwise, all religions are similar in holding humanity's best interest at heart.

Let us follow Dr. Livingood's advice and look beyond the borders in our lives.

References

1. Livingood C. Clarence Livingood, MD. Interview by Victor H. Witten. Cutis 1999;63:10-12.

2. Carroll CL, Feldman SR, Camacho FT, Manuel JC, Balkrishnan R. Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use. J Am Acad Dermatol 2004;51:212-6.

3. Feldman SR. Tachyphylaxis to topical corticosteroids: the more you use them, the less they work? Clin Dermatol 2006;24:229-30.

4. Carlin CS, Callis KP, Krueger GG. Efficacy of acitretin and commercial tanning bed therapy for psoriasis. Arch Dermatol 2003;139:436-42.

5. Fleischer AB Jr, Clark AR, Rapp SR, Reboussin DM, Feldman SR. Commercial tanning bed treatment is an effective psoriasis treatment: results from an uncontrolled clinical trial. J Invest Dermatol 1997;109:170-4.

6. Anderson R, Barbara A, Feldman SR. Seven Traits of Outstanding Physicians as Reported by Their Patients. http://www.drscore.com/press/releases/7traits.pdf. Accessed May 30, 2006.

7. Feldman SR. Top 10 psoriasis treatment tips. G Ital Dermatol Venereol 2006;141:55-62.

8. Hill MJ. iPLEDGE: protecting patients or prohibiting access to care? Dermatol Nurs. 2006;18:124.

9. Renzi C, Tabolli S, Picardi A, Abeni D, Puddu P, Braga M. Effects of patient satisfaction with care on health-related quality of life: a prospective study. J Eur Acad Dermatol Venereol 2005;19:712-8.

10. Stelfox HT, Gandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice lawsuits. Am J Med 2005;118:1126-33.

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