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Bolognia Advises ‘Stepping Back’ to Aid Diagnosis
A lecture that evokes fried eggs, kale and fried chicken might seem like the perfect noon-hour assignment. Unless, of course, the talk likens such food to skin lesions, complete with life-size four-color illustrations. Then the plum job could easily become a lunchtime chore only dermatologists (and their closest medical friends and scientific relations) would love.
That is, unless the lecturer happens to be esteemed Yale School of Medicine professor Dr. Jean Bolognia, editor of Dermatology—arguably the bible of textbooks on skin disorders. At an Oct. 23 Clinical Center Grand Rounds in Lipsett Amphitheater, Bolognia gave a clinic—both on diagnosing complex dermatological disorders and on simultaneously engaging and informing an audience.
Her lecture, “Stepping Back Is Sometimes Better Than a Closer Look,” was the latest session of the CC’s Contemporary Clinical Medicine: Great Teachers series. Her title served as an analogy involving pathology, histology and perspective—employing both a dermatologist’s tool-in-trade and a veteran physician’s experience and insights.
“This isn’t exactly an anti-dermatoscope talk,” Bolognia explained. “Rather it is a push for us to continue to think about the 4x clinical exam as well as the 100x clinical exam…When you look at 4x with a microscope you see an overview, then you go to 20x and sometimes to 100x. We can do that clinically as well. My push is for the 4x exam. What I’d like you to do in the future is to step back and drop the dermatoscope.”
Bolognia then presented several cases that, if viewed too closely and without the context distance provides, could confound novice as well as seasoned physicians. Consider, for example, the visual similarities between two conditions seen in hospital patients—a generalized bullous fixed drug eruption and toxic epidermal necrolysis (TEN)/Stevens-Johnson syndrome (SJS).
“When I think about the difference between a morbilliform eruption due to a drug and SJS, I think of Kentucky Fried Chicken,” Bolognia said, to amused gasps from the audience. The former is KFC original recipe, she explained, whereas SJS presents additional characteristics, such as fragility and sloughing, and should therefore be categorized as “extra crispy.”
Warning, non-dermatology folks: Under no circumstances should you Google these terms for images.
“So, how would you treat a patient with TEN after you have established the diagnosis?” she said, showing a slide of lesions labeled with final diagnoses. “You have to decide on your favorite flavor. There’s only one randomized clinical trial. This is dermatology—we do a lot of cooking in the kitchen without a recipe. We’re chefs, not cooks.”
Bolognia also advised budding dermatologists to recognize that, in general, individuals often make their own unique types of moles (technically called nevi). If you can determine these “signature nevi” early in an initial examination, she counseled, then you can eliminate them as worrisome lesions (“unless there is a superimposed change”) and concentrate on “the outlier nevus—the ugly duckling. It will make your life a lot easier.”
Next, Bolognia addressed nevi that resemble fried eggs. Oftentimes, she noted, these moles draw a lot of attention from worried patients, parents and pediatricians.
“For a good reason,” she pointed out. “They are large, they are noticeable. They are in a way sensational, but yet they have done nothing to have earned that reputation. So I nicknamed them the ‘Kardashian nevi,’ because I feel they’ve done nothing but be sensational because of their size and their look. These do not need to be removed unless there has been a superimposed change. Save the nevi! Save the biopsy for when you need it. Plus, when you remove these nevi, you often leave an unsightly scar because of their common location on the posterior trunk.”
Another common type of signature nevus looks like a solar eclipse, she pointed out. It’s generally “bland and innocent” and is often found on the scalp of children who will develop an increased number of nevi over time.
Throughout her lecture, which was rich with humor and anecdote, her message was clear: Be careful, deliberative and open-minded in your observations, opinions and consultations. Both you and your patients will be better for it.
“I think in medicine we are starting to move too fast to treatment and not taking the time for differential diagnosis,” she said.
Bolognia closed her lecture with a nod to more than a dozen of her own teachers, mentors and colleagues she referred to as “characters.”
“All the characters pictured here have passed away,” she said, posting a slide filled with portraits. “Some I agreed with from the day I met them and some I never saw eye to eye with, and although we fought like cats and dogs, we remained friends…We’re losing the characters in medicine. And I’m trying to bring them back. We don’t have people who stand up and passionately argue about the diagnosis anymore. We’re getting too homogenized in medicine. We’re not arguing enough anymore.”
During the Q&A period, Bolognia was asked her view of contemporary medicine and medical training.
Recalling her own experiences as a med student, a resident and early days in her career, she reiterated the impact of having great teachers. Students in any field, she said, should never put themselves in a position where “all you know is what you’ve been taught by others…Take the best of several people as well as multiple books. Then combine those ingredients and be unique. I also don’t believe everything should be taught in the classroom.
“Dermatology,” she concluded, “still has a lot of apprenticeship learning—one on one, in the room with the patient. I still think that is a good way to learn—right at the bedside, not in the classroom.”