When I walked into Elisa’s room, I immediately felt the cosmic rush of excitable energy I typically only experience when I step off the train into New York City’s Penn Station – the room was electric. Clinic had been running late and, in the meantime, this 8-year-old had remade the exam room into her playground. Crayons littered the area, abstract shapes covering the exam table paper. She’d exchanged her clothes, strewn on the floor and chair, for a twisted hospital gown and her own bright pink socks. She immediately leaped up and loudly introduced herself to me while her mother patiently sat in the corner, clearly accustomed to the Elisa show. This little girl owned the room and oozed confidence; remembering my own childhood shyness, I admit I was a bit impressed.
Elisa and her mother had driven an hour to our clinic after having difficulty accessing care in an underserved area of Massachusetts, so I wanted to make the most of their visit. Over the next 20 minutes of her dermatology appointment, we succeeded in many things: an exam and testing confirmed and staged Elisa’s diagnosis; I educated the family about her condition; we discussed the risks and efficacy of available medications and procedural treatments; I started the cascade of behind-the-scenes work of prior authorizations and insurance claims to ensure Elisa could access the therapies we were recommending to her; and I provided emotional support to Elisa’s mother who was finally able to unload the concern she had been carrying for months.
At first, I felt good about what we accomplished in our allotted time. However, as I was concluding the visit, I realized the room felt markedly different. The spark was gone. On the table, there was now a little girl playing with her hands, eyes cast downward. As I reflected on the visit, I realized that for all we had accomplished, we had also likely failed in a significant way.
Elisa has vitiligo, an autoimmune condition that causes depigmentation of the skin. I am two months into my residency program in dermatology and five years into my medical training. I am well-versed in the cellular pathogenesis of vitiligo and have been finessing my patient communication skills since I began training. That said, Elisa helped me realize that treating visible disease, especially in pediatric patients, comes with a unique set of challenges that require clinicians to lean into mastering the “art” of medicine, in addition to mastering the science.
In a field that treats visible disease, the line between medical and cosmetic intervention is inherently blurred. Children often present to the physician’s office because they don’t feel well; perhaps their behavior has changed, they’re running a fever, a parent notices a cough, or is worried about a lack of appetite. Our pediatric patients in dermatology may present symptomatically with the classic itchy rash of eczema or wanting to discuss their acne — but they also often present because someone else noticed something of concern, be it a spot, some bumps, changes in pigment, or a visible rash. As we discussed Elisa’s vitiligo in the exam room, pointing out and dissecting a disease that was affecting her face, hands, hair, and appearance, I couldn’t help but wonder: what was she hearing?
In dermatology, many medical conditions affect how a patient looks and therefore have a built-in element of cosmesis. This adds a layer of nuance to every patient encounter as we try to treat, manage, or cure our patients, while simultaneously encouraging them, building them up, and managing their expectations. It becomes even more challenging when interacting with children. When discussing skin disease with pediatric patients, are we implying that something is wrong with the way their skin looks — with the way they look?
With these concerns in mind, I have developed a litmus test for myself: if our time together has resulted in the patient quietly staring down at their hands when they were previously making eye contact, I will pause to re-engage the patient. Asking open-ended questions such as: “What do you think about the spot on your cheek?” or “How does your hair loss make you feel?” brings the child back into the conversation and provides a natural bridge to the discussion of care. Their answers can be surprising. I also try to offer alternate reasons for treatment besides cosmesis (e.g., “I know these spots don’t hurt you, but they can spread, and we want to do our part to protect your friends and family.”) Additionally, naming the condition explicitly allows us to discuss the diagnosis and treatment rather than the body part or appearance: “Phototherapy is a commitment, but it can be a very effective treatment for your vitiligo,” versus: “Coming in for phototherapy may help the white spots around your mouth and eyes go away.”
Vitiligo can be a terribly distressing disease, and I understand when parents want to do whatever they can to spare their child from suffering, now and in the future. While adult patients can dictate whether the cosmetic element of their skin condition bothers them, and if they would like to discuss it with their clinicians, children are not always in control of that choice. Physicians should take extra care in communicating with pediatric patients and their families regarding skin disease — and keep in mind the untold message behind our words. This is especially important when a condition is not actively symptomatic, as cosmesis may become the default therapeutic focal point.
For my part, I am always reminding myself that I’m in residency both to master the science of my specialty and to continue to hone the art. When I see Elisa back in clinic for her first phototherapy session next month, I hope she’ll give me a chance to do just that.
How do you tailor your language to fit particular patient populations? Share your strategies in the comments.
Rebecca Yanovsky Dufner, MD, MBA is a resident physician training in dermatology in Boston, MA. She graduated from Stanford University, Tufts University School of Medicine, and the Heller School for Social Policy and Management. In addition to her passion for dermatology, she has led cross-functional teams in health care and in tech, and is interested in health outcomes, access, and delivery on the patient and population level. Rebecca is a 2021–2022 Doximity Op-Med Fellow.
All names and identifying information have been modified to protect patient privacy.
Illustration by April Brust