*Keywords: Dermatopathology, skin specimens, physician burnout, emotional intelligence, detachment, empathy.
*The author has no conflicts of interest to report.
Preparing Dermatopathology Specimens in Proper Context by Travis Dowdle*
As a specimen grosser, I am frequently greeted by samples like this one. Abnormal, soaked in formalin, and disconnected. Without the labeling on the jar there would be no way to ascertain the origin of this tissue. The face and story of this person it was taken from are unknown to me.
“Every piece is a person,” Dr. Michelle Tarbox, associate professor of dermatology at Texas Tech University Health Science Center mentioned before going on to explain other important elements of the position then looping back to the main point: Make sure you keep the proper perspective that these samples are integral for the diagnosis and management of real people. She was referring to my position as a grosser in the dermatopathology lab where I would be preparing skin biopsies and excisions for histological evaluation. As an aspiring dermatologist, I was ecstatic to be given this opportunity.
One year later, I reflect on Dr. Tarbox’s word choice and that she specifically used the word person rather than patient. It’s a subtle yet profound difference, especially for those of us in healthcare. Patient conjures an image of an individual in a gown with no life outside the hospital while person elicits thoughts of someone with hopes, aspirations, feelings, and failures. Each person comes into our world momentarily but will inevitably step back into his own, surrounded by loved ones who care about his wellbeing and dermatology visit.
As I cut through this squamous cell carcinoma excisional specimen, I think about the patient waiting by the phone for his results. He may not have suspected that this itchy bump on his neck was anything more than an irritated bug bite. Perhaps he is a local cotton or peanut farmer who works long hours in the sun. I also frequently think about my mother, who died of colon cancer three years ago, and the family gatherings we had whenever she would receive any lab, surgery, or test result. Channeling these thoughts as I work helps as I connect with patients I don’t know.
Implications
Do my own personal attempts to emotionally attach to dermatopathology samples from patients have any broader relevance?
Empathy is the ideal balance between emotional over-involvement and detachment. Physicians are required to be both clinically competent and empathetic toward patients. In practice, it is difficult to find the right balance between being technically skilled and objectively, professionally, and emotionally engaged, yet not over-identifying with a patient’s distress [1].
When physicians experience burnout, their ability to strike this balance becomes diminished. This can lead to negative, cynical, hostile attitudes and detached feelings toward patients. This is known as depersonalization, where physicians treat patients as objects rather than human beings [2]. Physician burnout is related to factors such as an increasing workload related to EHR documentation, clerical, and administrative duties, coupled with a shrinking number of meaningful interpersonal interactions and high patient volumes [3]. While dermatology in the past had low levels of self-reported burnout, it has been steadily increasing in recent years [4].
Many in healthcare don’t directly interface with the public, as in my current role as a grosser. Those who do are seeing a shrinking number of daily, meaningful interactions with increasing levels of documentation burden and patient volumes, as is the case of many physicians. This can potentially lead to patient care becoming rote and emotionally draining.
There are no simple solutions for staying connected to those we treat. My suggestion echoes the words of Dr. Tarbox to keep in mind that every specimen is a person. This sentiment applies to more than skin samples and reminds us we must not become complacent, rushed, or lose sight of the importance of what we are doing.
In 2008, two Israeli radiologists performed a study in which they attached patient photographs to CT scans, attempting to evaluate if this could increase connection and empathy towards patients they had not interacted with. They described that this did not lengthen the duration of the examination, however, it did render the interpretation more meticulous and increased radiologists’ levels of empathy. All who participated recommended adopting this practice routinely [5]. This could easily be applied to specimen preparation and visualization in dermatopathology. More research should be undertaken to explore this relationship given that self-reported burnout in dermatology is increasing [4].
It is difficult to constantly re-evaluate our mindset in an attempt to view every sample, chart, or surgical procedure or study as important, but it is vital to remember someone’s mother, father, or brother is always being treated.
*Author Bio: Travis Dowdle is a 2nd year medical student and aspiring dermatologist and Mohs surgeon at Texas Tech University Health Science Center School of Medicine (TTUHSC) in Lubbock, Texas.
References:
1. Kerasidou A, Horn R. Making space for empathy: supporting doctors in the emotional labour of clinical care. BMC Medical Ethics. 2016;17(1):8. doi:10.1186/s12910-016-0091-7
2. Patel RS, Bachu R, Adikey A, Malik M, Shah M. Factors Related to Physician Burnout and Its Consequences: A Review. Behav Sci (Basel). 2018;8(11). doi:10.3390/bs8110098
3. Carmen MG del, Herman J, Rao S, et al. Trends and Factors Associated With Physician Burnout at a Multispecialty Academic Faculty Practice Organization. JAMA Netw Open. 2019;2(3):e190554-e190554. doi:10.1001/jamanetworkopen.2019.0554
4. de Moll EH. Physician burnout in dermatology. Cutis. 2018;102(1):E24-E25.
5. Yehonatan Nizan Turner MD, Irith Hadas-Halpern MD. The Effects of Including a Patient’s Photograph to the Radiographic Examination. Presented at the: Radiological Society of North America; February 18, 2008; Chicago, IL. Accessed August 14, 2020. http://archive.rsna.org/2008/6008880.html
From Bhushan Kumar, Chandigarh, India: “Nice expression of feelings / difficulty in orienting the specimen – which without the requisite information is more like a ghost. We tried to solve this problem by organizing dermato-pathology conferences – where the dermatology residents who do the biopsy would realize (and hopefully become wiser and more responsible) the difficulties of a pathologist in the absence of a requisite information. But the problem for the pathologist is real.”
Brooklyn, NY dermatologist Stephen Danziger writes: “Travis Dowdle’s observations and feeling about who is attached to a biopsy specimen and who is not just an accession number, is a reminder that whatever we do in health care it is about people and not about satisfying corporate compliance officers in a huge health care corporate “enterprise.” (Do you know how to use a fire extinguisher?) Unfortunately, impersonalization has occurred as large corporate entities and big medical groups and hospitals buy traditional solo practices and make physicians drones who work for the satisfaction of the CEOs and their bottom lines. They are aided by electronic health records, the primary function of which is for billing with a secondary purpose of record keeping and retrieval. These old timers are told that they can give 10 minutes of care to their patients, and, in effect, are piece workers. No more schmoozing with the patient, even if it puts them at ease. Is this what we thought we would do when we decided to go to medical school?”
I never liked the word “case” when referring to a patient. At meetings, there are often sessions of “my most interesting cases” where photos of lesions are presented without seeing the whole patient. What is wrong with presenting a “most interesting patient” who happens to be attached to a disease? This kind of jargon becomes ingrained and automatic and is not even considered when speaking to colleagues.
I remember my neuropathologist in medical school (SUNY Downstate Medical Center), the late Dr. Stanley Aronson, who would show us slides of diseases of the brain and then tell us of the effect on the patient and family, making the condition a part of a whole picture of a patient, not just about a slide we were viewing. He moved from Brooklyn to Brown University in Providence, RI and was a founder of its Warren Alpert Medical School. I met him after many years, when my son graduated from Brown, after meeting a classmate’s mother, the daughter of another Downstate professor, Herbert Lichtman, MD, a wonderful hematology teacher who went with Dr. Aronson to Browm. Dr. Lichtman’s daughter told me that Dr. Aronson was to be feted the following day at a special reception in his honor, and I was invited. It was a very emotional reunion with him and we reminisced about our days in Brooklyn.
He passed on a couple of years later and I would like to share with you an obituary that summarized what a wonderful and inspiring person Dr. Aronson was:
https://news.brown.edu/articles/2015/01/aronson
It won’t be easy to maintain the qualities of what it means to be a good physician of the future but every generation has its tasks to hurdle and with the right ideals, can retain what is important My son, whose attendance at Brown allowed my reunion with Dr. Aronson, just graduated from my alma mater, State University of New York, Downstate Medical Center, recently rebranded as SUNY Downstate Health Sciences University–if only new names really made a difference– and I know that his experience as a physician will be vastly different from mine but he is passionate about being a physician and I know that he will be a most valued asset to our profession (I am sorry to be boastful, but he has great ideals that will make him a success).
from Warren Heymann, M.D. “Beautifully written. I would like to make two points, the first echoing Dr. Tarbox. When I sit at the microscope for the first time with new residents I hold up a slide and ask them what it is. Inevitably they say it’s a slide, and I correct them, telling them that it is a slide of a specimen taken from a real person, who is concerned about the diagnosis we are about to render. Secondly, colleagues and staff would never dream of coming into an examination room while I am with a patient, without politely knocking on the door, yet, have no qualms about interrupting me while I am concentrating on reading a slide.” Sincerely, Warren