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A Little Reticence May Not be a Bad Thing…

A Little Reticence May Not be a Bad Thing…

Feldman headshotI get to review a lot of dermatology articles. One of my pet peeves is when an investigator finds a higher risk of something and concludes that we ought to screen for it more aggressively without considering the risks and other costs of doing the screening. For example, we know there’s a higher risk of cardiovascular disease in our patients with psoriasis, and based on this, some have concluded we need to do more cardiovascular screening in these patients than we would in similar people who don’t have psoriasis. However, such a recommendation ought not be made until we balance the potential benefit against the costs of the screenings and the risks and other costs of false positive results; ideally, you would also want some data that showed that acting on the screening results improved patients’ outcomes. All too often, the recommendations people make don’t take into account all the factors that should be considered. We want the best outcomes, and we have to balance the risks and cost of action vs inaction. When we try to do that, we might find that the best path is not obvious, that we don’t have all the information we need, and that good judgment needs to be used.

The tendency to leap to a particular conclusion can be exacerbated by an anecdote. Humans are moved by stories, even (or maybe especially) by stories of just one person. If one of our psoriasis patients had an early heart attack, we might be especially moved to screen psoriasis patients for cardiovascular disease more aggressively, even if we don’t have a lot of data to support doing so. That one heart attack might be especially moving to us if we saw it happen in our office or saw a 9-minute video of the person clutching their chest in pain, short of breath, diaphoretic, and being wheeled into the emergency room. We desperately need to prevent heart disease, but we also need to be rational and make sure the actions we propose to use will improve patients’ overall outcomes and not create more problems than they solve.

While these issues are common in medicine, these tendencies to make judgments based on a limited analysis and to be moved by anecdotes aren’t limited to medicine. Similar phenomena may be at work in some of the recommendations we see being offered as solutions to the horrible problem of racial injustice in the United States. One anecdote of a horrific killing moves people to finally take action; others might be moved in a different direction by their knowledge of a police officer who had been killed in the line of duty. Getting rid of the police altogether may be an effective way to eliminate police violence, but the cost might be (I don’t know; I don’t yet have the data to know what would happen) far greater death and mayhem in communities that we are trying to protect.  

It’s easy for me to be reticent about jumping to conclusions, because the context in which we see things has a strong effect on our perceptions. I’m a well-fed, light-skinned, male dermatologist, living in a safe suburban neighborhood who has had only respectful interactions with police. Trying to see things from the perspective of people who have a different context is a difficult but important skill to master, both for being a good physician and for being a good citizen. Trying to communicate with people—patients or otherwise—when they are in a heightened emotional state is extraordinarily difficult (if you don’t believe me, ask Drew Brees).  Trying to see past our own biases and listen, truly listen, to what others are trying to say, when we ourselves are either emotionally invested or rooted in a partisan view, is nearly impossible. 

This issue features a guest editorial from our friends at the Skin of Color Society and the National Medical Association (page 13). Their perspectives on the treatment of skin of color, whether in the different phenotypic presentations of atopic dermatitis (page 34) or in the cultural barriers to care outcomes in people with albinism (page 41) or in another dermatologic condition, is incredibly important during these times.

It might be best for us to take a moment to pause to quietly comprehend others’ thoughts and feelings as a necessary step to improving relationships and everyday life.

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Steven R. Feldman, MD, PhD
Chief Medical Editor

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