One of my colleagues sat on a wheeled clinic stool at the end of the examination table and told the patient, which was in this case an actor, “Everything looks great.” After, he swiveled around to face the instructor and the small group of onlooking medical students behind him. Our instructor also turned to us and said, “Very good job. But can anyone tell me what he did wrong?” He had done everything correct I thought, and the rest of the students must have felt the same way because they didn’t speak up either. I replayed the encounter in my head.
First, he introduced himself to the patient, which was, in this case, an actor, then he described the purpose of the exam. He next asked her to move her bottom down to the edge of the table, “until she felt his hand.” He asked her to “let her knees fall to the side” rather than inappropriately telling her to “spread her knees.” He performed the exam properly and was able to, remarkably, find the cervix on his first try. He had even introduced her skin to the temperature of the speculum and announced his touch on her leg before beginning the vaginal exam, two things the instructor identified as commonly overlooked by students. Despite going over his examination again in my head, I couldn’t figure out what he had done wrong.
To alleviate the awkward silence, the actor attempted to help us by hinting, “It isn’t anything he did. It’s something he said.” To which we each responded with a collective, “Ohhhhhh!” indicating we had known all along but weren’t confident enough to answer. Our instructor then reinforced the important learning point: Never say to the patient that anything “looks good” during a physical exam, instead tell the patient that whatever you are examining looks “normal” or “healthy.”
It is an important communication competence to have as a clinician, especially when performing examinations that involve sensitive body parts such as the genitals. And it makes sense. To have a stranger calling your private parts “good” can have an uncomfortable or dangerous sound to it, even if uttered out of naivety. But it can also be an imprecise or even confusing term to use in other less invasive parts of the physical exam. For example, “your heart sounds good” is much less reassuring than “your heart sounds healthy, I do not hear any murmurs or other abnormal sounds.” It is for both of these reasons that it is taught to medical students to avoid words like “good” or “great” and to instead use “healthy” or “normal” when discussing physical exam results.
However, in my training in medical school, I have come across one important instance when using words like “good” or “great” may actually be of benefit to the patient: in the dermatology clinic.
In my last year of school, I began rotating with several different dermatology programs in different cities and schools, something many applicants to the field of dermatology do to learn, show interest, and increase their chances of matching into a dermatology residency program. I was exposed to many amazing aspects of the career of dermatology, and one that struck me most was the unique way that dermatologists interacted with their patients. Specifically, they made frequent use of those forbidden words that medical students were taught to avoid. “You look great!” or “Your skin looks so good!” or even, “Your skin is doing so much better. You look amazing!” were not uncommon phrases used by many dermatologists I followed. And it wasn’t just unique to any one program or any part of the country. In fact, it was ubiquitous.
The use of such language by dermatologists is not a mistake and is in reality quite purposeful. So many of the diseases of the skin, whether they are medically harmful or not, have genuine, undisputable effects on patients’ lives. Disorders of the skin are unlike any other in that they are often visibly noticeable and, in some cases, the first thing that is presented to the world and other people.
Sometimes even treatment modalities can draw unwanted attention to the skin in the form of scars, sutures, inflammation, dryness or other appearances that are undesirable to many people.
It doesn’t take a large imagination to realize that it can be tremendously distressing to live with such a condition. Many people with dermatologic diagnoses may feel self-conscious about their appearance, and this, I believe, is where the importance of reassurance by a dermatologist can come into play. It’s empowering as a patient to hear from a skin expert that their skin has not only improved with treatment but is looking terrific to boot. It not only creates a strong bond between clinician and patient, but it also encourages the patient and lets them know that they can feel good about the way they look. Almost without fail, patients seemed to leave the clinic with a smile on their face whenever such phrasing was used.
I have seen the influence of this clinical skill in adults, but I must admit that I was especially touched by the effect it had on children. During both a pediatric dermatology rotation and my time volunteering at a camp for kids with chronic skin conditions, I saw some variation of this phraseology used many times. Whether a child with alopecia totalis was having impressive hair regrowth or a child with severe eczema was making only minimal improvements despite the use of systemic medications, whenever a young child was told their skin or hair or just they themselves, looked great, I would notice, at the very least, a sparkle in their eye and, at the very most, an ear-to-ear grin.
There’s a power to that — helping a patient feel better about themselves. And dermatologists are privileged to have the opportunity to do just that in unique ways compared to other specialties in medicine. I was grateful watching dermatologists support their patients in such a truly profound way, and I cannot wait to be able to offer the same uplift to my future patients.
Brooks David Kimmis is a dermatology resident.
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