Optimizing the dermatologist-patient encounter

By Warren R. Heymann, MD, FAAD
Oct. 5, 2022
Vol. 4, No. 40

My celebration of the USA bicentennial on July 4, 1976, was a glorious affair. I had taken my first plane flight at age 21 to visit Boston, culminating with Arthur Fieldler and the Boston Pops performing Tchaikovsky’s 1812 Overture accompanied by pyrotechnics dazzling the Charles River’s sky. What a memory! When I returned to medical school, my first patient encounter during my psychiatry rotation was an inconsolable middle-aged man who was distraught and tearful. When he could finally express what was troubling him — that he would not be alive for the tricentennial — I instantaneously realized that I could not be a psychiatrist as I summoned all my energy to hold back my laughter. No, I needed to find a discipline where the data was visible and objective. Dermatology fit the bill when I was subsequently introduced to the specialty. Ultimately, though, the last laugh is on me. Little did I understand that to be an effective dermatologist you need to be a good psychiatrist and a superb psychologist.

Dermatologists are familiar with psychodermatoses (delusions of parasitosis, factitial ulcers, body dysmorphic disorder, etc.) and the deleterious effect that chronic disorders such as acne vulgaris, psoriasis, and atopic dermatitis may have on the psyche and quality of life. This commentary, however, focuses on the psychology of the doctor-patient relationship. This commentary was prompted by a request from Christine Ko, MD, Professor of Dermatology at Yale, that I peruse her new book How to Improve Doctor-Patient Connection: Using Psychology to Optimize Healthcare Interactions (Routledge, New York, 2022, pp1-296). Full disclosure — Dr. Ko and I are friends who work together as Directors of the American Board of Dermatology.

Each of us has experienced patient encounters that alter how we practice. For me, it was a woman with (presumed) DRESS syndrome that I diagnosed early in my career. Medically, I handled it perfectly. I stopped the inciting culprit drug, placed her on prednisone, and asked to see her back a few days later. I did not recognize her — the rash was almost resolved, and I was delighted. I was taken aback by her anger — the only reason she returned was specifically to lambaste me because “you might know what you’re doing medically, but as a physician you failed me — you were more concerned with my rash and did not address my fear or concerns at all.” Lesson learned. She was right. Ever since, I sit down with every patient, ask about how they are in general, what other medical problems they have, and how their emotional state is vis-à-vis their dermatologic problem. (Fortunately, this occurred before the internet, so her experience did not go viral. I also wish patients would understand that direct complaints to the provider can be far more effective in changing behavior than ranting to the cyber-universe, which is more likely to breed resentment in the physician instead). For Dr. Ko, it was a patient who felt that the physical examination provided by Dr. Ko was cursory. Even a missed actinic keratosis (how many thousands have I missed over the years?) was enough to sever the relationship.

Medicine must be viewed from the patient’s vantage point. To use an analogy, think of the last time you had to call your cell phone provider attempting to speak to a human being about your problem. You called the 800 number, went through several prompts, constantly got reminded that you could handle your concerns on their website, were placed on interminable hold listening to ungodly music (or worse, ads for their other services) and, if lucky, spoke to an actual human being within an hour, who had the temerity to say, “Hello, I hope you’re having a good day!” as you’re about to pop a cerebral aneurysm from a drastic elevation in blood pressure.

The doctor-patient relationship is the crux of our existence. This has been put to the test — the difficulty securing an appointment, the mountain of paperwork before being seen (either in person or by telehealth), followed by a time-limited face-to-face (or face-masked-to face-masked) encounter. Is it any wonder that many patients feel dissatisfied? Are you surprised when doctors complain of burnout when scheduled with so many patients in the course of the day, most with several issues to be covered in compressed time with a patient who may be on edge? These systemic issues, if not corrected, put us behind the proverbial eight ball, and must be addressed for patient satisfaction. That being said, once in the examination room, we must make every moment count.

Dr. Ko takes us through this journey from her perspective as a worried mother whose newborn child had profound deafness that was not recognized initially. It is heart-rending to learn of her devotion to her son, the choices that needed to be made, and his ultimate success despite the question of whether his cochlear implants would help him. I was touched by how she was ready to abandon a talented auditory verbal therapist because of a blunt comment that “colors will get you nowhere in life” after Dr. Ko was thrilled that her son was finally speaking and identifying “blue,” “red,” and “yellow.”

Dr. Ko delves into the importance of being human, becoming ourselves as physicians, not just someone else’s ideal of what a physician should be. She embraces “metacognition” — the act of thinking about how our behaviors affect the doctor-patient relationship. Communication is key. How we present ourselves in appearance (she now wears the white coat again — I have never taken mine off), how we speak (tone, cadence, clarity), how we look into patients’ eyes, making sure we listen (not just hear), and develop an emotional intelligence are all skills that can be honed with practice so that they become habitual. I found the discussion about managing basic human emotions (anger, disgust, fear, happiness, sadness) and channeling them to a positive outcome enlightening. Getting to the right balanced planes of emotion for the patient and physician is essential in having an optimal encounter.

Ample time is devoted to understanding Dr. Daniel Kahneman’s constructs for two major thinking patterns — fast thinking (System 1, a gut reaction, habit, “expert” thinking) and slow thinking (System 2, which is more conscious and controlled). As dermatologists, we are trained to use System 1 most of the time, however, that may not lead to the right conclusion. Nor does reliance on System 2. The reality is that the combination of the two, while being cognizant of our thought processes regarding how we reach conclusions, is likely to provide us with valuable insights.

The most important aspect of reading Dr. Ko’s treatise is that it enticed me to think critically about how I practice. I devoured the book over two evenings and decided this morning that I was going to concentrate on presenting my best self to every patient. I understand that not every visit will be ideal, and there will always be disgruntled patients for a variety of reasons (too long a wait, an incorrect diagnosis, a therapy that did not work as expected, ad infinitum…) Despite that realization, I focused, looked, and listened with redoubled effort. My new patients thanked me for wonderful visits. I felt energized. Thank you, Dr. Ko for reminding me what practicing dermatology is all about.

Point to Remember: No matter how seasoned we are as dermatologists, we owe our patients, and ourselves, care that optimizes the patient-physician encounter. Metacognition is really thinking about what you do and how you do it. Take the time to be self-analytical. You and your patients will see the difference!

Our expert’s viewpoint

Christine J. Ko, MD, FAAD
Professor of Dermatology and Pathology
Yale School of Medicine

I am honored that my colleague and friend was willing to take the time to read my book. Even more, it is truly meaningful to me that his new patient visits were infused with energy and joy as a consequence. The COVID-19 pandemic has stripped us all of many things in the past 18 months, particularly social interaction as we used to know it. Health care and the doctor-patient interaction have been severely taxed at different time points, in various geographic areas. As a physician and parent, I have struggled mightily at times with competing interests (e.g., the burden of virtual schooling placed on parents vs. working full-time), and the cognitive psychology concepts in this book have illuminated my choices and responses many a time.

In a nutshell, there are four main concepts in the book. Firstly, metacognition is thinking about thinking, (1) and as a corollary, metaperception is thinking about our perceptions in terms of what we see, what we hear, and what we feel. A second important effect is that put forth by Drs. Dunning and Kruger, which has demonstrated with high fidelity that many individuals (including physicians) are unskilled and unaware, particularly if very unskilled. (2) Dr. Carol Dweck’s concept of a growth mindset, in which challenges and failures are welcomed as opportunities for growth, is a third important idea. (3) Lastly, deliberate practice has been fleshed out by Dr. Anders Ericsson and popularized by Malcolm Gladwell; (4,5) deliberate practice being working on something in a short time frame with immediate feedback and reflection. These game-changing ideas can all be directed at becoming aware of your own power to influence any given interaction, with particular focus on doctor-patient connection.

As Dr. Heymann writes, “once in the examination room, we must make every moment matter.” Creating habits of observing, listening, and emotional logic has helped me to practice the type of medicine where I can do my best to connect with my patients, despite all the systems factors stacked against us. Practicing doctor-patient connection continues to be a learning process, and while I am not always successful, I am more cognizant of the joy and privilege of being a doctor.

1. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2011.

2. Kruger J, Dunning D. Unskilled and unaware of it: How difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J Pers Soc Psychol 1999;77(6):1121-1134.

3. Yeager DS, Hanselman P, Walton GM, Murray JS, Crosnoe R, Muller C, et al. A national experiment reveals where a growth mindset improves achievement. Nature 2019;73(573):481-496.

4. Ericsson KA. Deliberate practice and acquisition of expert performance: A general overview. Acad Emerg Med 2008;15(11):988-994.

5. Gladwell, M. Outliers: The Story of Success. New York: Little, Brown and Company, 2008.

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