12 Things I learned from my summer with Dr. Pearlman
Hari Parthasarathy, July 2019
From a very young age, I have been very interested in biology and medicine. This summer, I got a chance to learn more about both when I got the opportunity to shadow Dr. Dale Pearlman over a period of two months.
Dr. Pearlman is a board-certified and nationally recognized dermatologist who has been helping patients for more than four decades at his clinic at Menlo Park. A graduate of Stanford University Medical School, he has also been a member of the faculty at Stanford (dermatology department) and has researched and published extensively, including developing several new treatments for head lice and eczema.
As Dr. Pearlman mentions on his website (http://dalepearlmanmd.net/), he enjoys training medical students and young doctors, and when he offered me a chance to spend time at his office, I jumped at the opportunity. I was able to spend time over summer in Dr. Pearlman’s office, shadowing him during his patient visits, talking to him about his experiences and learning about dermatology but also learning how his office worked, how to be a good doctor and even some bonus life lessons beyond medical practice! The list below summarizes the top 12 things I learned during this time.
Biology in action
1. The fascinating practice of dermatology! Over a period of multiple weeks, I had the opportunity to shadow Dr. Pearlman in numerous patient sessions. I learned a lot about dermatology and saw biology in action! On my very first day, I learned a lot about nummular dermatitis, a disease much like eczema, caused by a bacterial infection in dry, cracked skin, and its treatment methods. Later, I learned about acne and how it is formed, and about papules, modules, and nodules (different types of bumps on the skin), about seborrheic keratosis (a type of skin growth), and even about a rare form of dermatitis, dermatitis herpetiformis (a chronic skin condition).
I also learned about how genes in the DNA can cause certain diseases. For example, breast cancer in women with the BRCA1 gene is significantly higher than breast cancer in normal women. Problematic DNA can also cause major problems in the skin as well. I learned about different types of biopsies and was able to witness liquid nitrogen freezing and a shave biopsy (used to identify cancers or other major skin diseases). I learned about tinea versicolor, a fungal disease that affects various parts of the skin and causes discoloration, and about mollescums (warts). I was able to learn about interesting side effects of antibiotics and the effects of biochemistry on dermatology, for example on how specific drugs can help prevent lip infections. I also learned about the different kinds of rashes and about hair loss and dandruff.
Not only do I now have familiarity with the vocabulary of dermatology, but I also have a strong appreciation of how concepts I learned in biology in school at a theoretical level have real-life application.
Medical practice in action
2. The two steps to diagnose a patient: In order to diagnose a patient, the doctor must go through two steps: description and differential diagnoses. The description is made up of two categories, the primary description and the secondary description. The primary description talks about the disease in relation to the part of the body the doctor specializes in (i.e skin). It also talks about any color changes in the skin. The secondary description talks about the distribution and the physical characteristics. These characteristics are then used to create differential diagnoses (step 2) which are a list of likely diseases. By using the characteristics captured in the secondary description, the doctor is able to narrow them down to one possible diagnosis. When the disease is undiagnosable, dermatologists tend to take skin biopsies to check with the lab. By learning this process, I was able to see the way doctors are able to rule out many diseases and come to a conclusion.
3. SOAP notes: One other medical practice I learned about was the “SOAP” technique. In the early 20th century, doctors didn’t have a structured and organized way of documenting their thoughts, and as such, their notes would be a jumble of ideas on paper. Lawrence Weed, an academic medicine specialist came up with the SOAP note method, an organized method of taking medical notes. SOAP is an acronym standing for four categories of notes: Subjective, Objective, Assessment, and Plan. Subjective is used to write down everything you hear from the patients (e.g., when their pain started, how long, etc.). The objective is what you can see during examination (e.g., red crusted papule on the left anterior thumb). Assessment is the diagnosis (e.g., dermatitis), and Plan is the next step in the treatment (e.g., “Apply cortisone on the spot for 1 week and come back in a month. Drastic improvement should occur in 5 days.”) On a similar note, I also learned about the importance of written prescriptions and ensuring that there are no mess-ups in the pharmacy.
4. Correlation is not causation: An important concept I learned about was the difference between correlation and causation. Patients often make assumptions about the cause of their diseases based on a correlation between two events. For example, a patient commented that “I went to Greece two weeks ago, and came back with a rash.” However, correlation is not the same as causation. In this case, the trip to Greece caused the patient’s body to tan, but the rash (tinea versicolor) did not, causing a sudden appearance of spots. The tinea versicolor was always there and caused by a fungal infection way before the trip to Greece. The patient correlated the two events, but the true cause was different. By remembering that correlation is not causation, the assumptions you make as a doctor can be more relevant to your diagnosis.
Bedside manner
5. Talking to the patient: An important aspect of a doctor’s effectiveness is their bedside manner. Being able to make the patient feel comfortable talking to the doctor allows the doctor to ask more personal questions and establishes trust between the patient and the doctor. One of the key things I noticed about Dr. Pearlman was that he always took the patient’s mind off the problem at hand by asking something about his or her personal life (e.g., What are you doing this summer? How are your children?). He was always willing to talk about what he was doing this summer, and opened up, acting almost as a friend would. This small talk allowed him to establish a friend-like relationship and build trust with the patient. He also had a good sense of humor that helped cheer up the mood when talking about serious topics. Dr. Pearlman also explained everything that was going to happen, from introducing me to the patient to explaining how a biopsy would work (even if the person had biopsies in the past). Explaining everything, Dr. Pearlman says, helps the patient not feel confused and be more aware of what is going on. Communication allows the patient to be on the same page as the doctor.
6. Patient courtesy: An important lesson I learned from Dr. Pearlman was on patient courtesy and respect. Many patients often came in with their assumptions and hypotheses as to how they got their disease: Last week, I was in Mexico, vacationing, and I was walking on the beach in Cancun when I met this dog … and after I came back, I noticed this big red rash in the middle of my tummy. Even though the patient might have meant well, most times, this is a correlation, not causation (see earlier discussion on proper medical practice). While the patient’s experience may provide some hints as to how the rash occurred, oftentimes, the story has no direct relevance to the diagnosis, except helping them ease their worry. However, it is still important to be courteous and listen carefully. Everybody likes to think they are right, and telling the patient that he/she is wrong can make them feel threatened, offended, and uncomfortable. It also loses the trust you have built so far.
7. Asking the right questions: One of the skills I really appreciated about Dr. Pearlman was his ability to ask the right questions. This may seem like common sense, but asking the right questions can go a long way in medical practice. If you were trying to diagnose heart disease, you won’t ask the patient the color of their car, as it has no relevance to the problem they are facing. Asking questions that are relevant to the topic and help you identify the diagnosis, is crucial.
Life Lessons
8. Underpromise, overdeliver: Most people won’t associate a technique like “under promise; overdeliver” with medicine; it feels more like a project management technique in the software industry! However, Dr. Pearlman pointed out how this tactic is an easy and effective way of increasing a medical practitioner’s credibility. If you have a patient who has a problem that should get significantly better in a week, saying that “it will get better in 2 days” is not going to benefit you as the doctor, or the patient either. Instead, saying that “dramatic improvement will occur in 2 weeks” gives you some buffer if things go wrong, and makes the patient feel that they recovered faster than the average person. By underpromising and overdelivering, patients feel that they can trust the doctor and they feel more comfortable coming back to ask other questions. This was a great life lesson about setting expectations and building trust that I will take beyond just doctor-patient relationships!
9. Shoot the basketball in order to make the basket: One of the things Dr. Pearlman said he would advise the younger generation, is about being open to trying out new things and not getting discouraged. He had a fun saying to encourage people to remember to try: “you need to shoot the basketball in order to make the basket!” Many people tend to not take the opportunity even when it knocks on their door. By constantly reaching out to others, looking out for new opportunities, and having a growth mindset, one can keep getting better.
10. Life-long learning: Dr. Pearlman approached every patient’s problem with a sense of interest as if it was a puzzle he was trying to solve. His constant enthusiasm and willingness to learn something new led him to create Orliderm, a company that uses products from Amazon to create a cream that could be used for treating eczema. Dr. Pearlman knew the science behind destroying the biofilm and attacking the bacteria that caused eczema. He also knew that standard cortisone cream didn’t help eczema, but that hand sanitizer was able to kill off bacteria in these regions. Relying on this knowledge, he was able to conduct an experiment to see if combining both of those had any effect in preventing eczema. On top of the standard cream, he created a stronger dose that contained mometasone, a moderate steroid. However, the results he got with this cream were only satisfactory, and he wanted to see if he could get better results with a different cream. Relying on the chemical makeup of certain cortisone creams, and their potency (their strength), he was able to choose triamcinolone, a similar cream that was much more effective in preventing the disease. His knowledge of biochemistry and his curiosity allowed Dr. Pearlman to create a new method to prevent eczema and nummular dermatitis among his patients. Dr. Pearlman’s love for learning extends beyond his work. Throughout the summer, he learned traveler’s German and Turkish to use during his trip to Austria and Saltzberg. At the risk of a bad medical pun, his love for learning was contagious!
11. The virtue of patience and compassion: Perhaps the most important life lesson I learned from Dr. Pearlman was on how to be a nice human being. Dr. Pearlman went to a great deal of trouble to provide a great learning experience for a high school student. The first day I started at his office, Dr. Pearlman took time to introduce himself, talk about why he chose dermatology, explain how the office worked, and explain key concepts. He explained how the staffers are split into front-end and back-end. Front-end staffers (receptionists) help with scheduling appointments and handling the waiting room, while the back-office staff help with rooming, prescriptions, and minor procedures, such as biopsies. Dr. Pearlman also described his background and how, after interning at the University of Cincinnati, he chose dermatology over (the then-popular) internal medicine because he liked the complexity of dermatology and its relationship with the immune system. His good nature extends to his patients too. Beyond his great bedside manner when they are at his office, he gives every one of his patients access to his personal email account, which allows them to follow-up with any concerns they have, even when they are back at their homes. Overall, working with Dr. Pearlman over the summer, I learned the importance of patience and compassion. I hope to pay this forward when I can.
Beyond school to work
12. Stretching and adjusting: This was my first time in a real work environment and it was an interesting experience stretching outside my comfort zone. I learned a lot about how to adjust to a new work environment, handle myself professionally in front of patients, connect with others in the office, and work and learn from Dr. Pearlman in his busy schedule. There was so much to learn — the biology surrounding dermatology, the technology in the equipment, the sociology of doctor-patient interactions, and the logistics of running an office — and I learned the value of listening and observing, and following up appropriately. My interest in biology has been amplified and the things I have learned have sparked more interest in dermatology that I hope to continue to learn more about. I feel very lucky about this opportunity and want to particularly thank Dr. Pearlman for letting a young high schooler like me spend time in his office this summer and learn so much.
