[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I have the pleasure of speaking to Dr. Dirk Elston. Dr. Dirk Elston is Professor and Chairman of the Department of Dermatology and Dermatologic Surgery at the Medical University of South Carolina in Charleston. He is very accomplished: a past President of the American Academy of Dermatology and the American Society of Dermatopathology, has served on the board of the International Society of Dermatopathology and the American Board of Dermatology, and currently serves as the editor of the Journal of the American Academy of Dermatology. Dr. Elston is a graduate of Jefferson Medical College, did his dermatology residency at Walter Reed Medical Center and completed a dermatopathology fellowship at the Cleveland Clinic. He is the author of over 600 peer reviewed publications, is one of the authors of Andrew's Diseases of the Skin, is Associate Editor in Chief of e-medicine dermatology and has a great textbook of dermatopathology, which I know a lot of trainees use, mainly with Dr. Tammy Ferringer, that received the highly commended award in the British Medical Association Medical Book Competition. He's received numerous awards, including the 2008 Walter Nickel Award for excellence in dermatopathology education, the 2013 Founders Award of the American Society of Dermatopathology and the 2021 Gold Medal of the American Academy of Dermatology. Welcome to Dirk.
[00:01:19] Dirk Elston: Thanks so much.
[00:01:21] Christine Ko: Can you share something about you personally with me and the audience?
[00:01:25] Dirk Elston: I'm a big gardener, or I'll say a frustrated gardener. I feed deer. I don't garden. I feed deer, and both my wife and I like to cook, and our daughter, who's also a derm/dermpath is big into cooking. So that's something we share as a family.
[00:01:43] Christine Ko: Oh, that's nice. One of my first sort of more meaty questions is - what does emotional intelligence mean to you?
[00:01:50] Dirk Elston: To me, it equates to empathy, the ability to think outside oneself and think of the other person and the other person's point of view.
[00:02:01] Christine Ko: The first episode for this podcast was on emotional intelligence because I felt that I never really learned about it. Since there are articles suggesting that empathy decreases in the third year of medical school and that there's compassion fatigue, and a lot of burnout among healthcare providers and actually everyone, you know, as the COVID pandemic continues- do you have ways of keeping that empathy alive, that emotional intelligence alive?
[00:02:26] Dirk Elston: I think the biggest reason why emotional intelligence troughs in the third year of medical school is lack of sleep; just overall fatigue. The best way to take care of others is take care of yourself a little first.
[00:02:44] Christine Ko: Yeah.
[00:02:44] Dirk Elston: Make sure you're sleeping, eating; that you're able to leave your concerns behind and really focus on the patient. And, you know, just reminding yourself and those around you, that there is a human being at the other end; it's not just a job, it's a human connection and we're trying to serve someone on the other side. It's a whole lot easier when you're not just running on adrenaline, just trying to finish the day.
[00:03:11] Christine Ko: I think you do have a sleep routine...
[00:03:13] Dirk Elston: Oh yes. Everyone makes fun of me because everyone knows I'm super early to bed and early to rise. A mentor told me long ago, find out when you're most productive. Some people are night owls. I'm a morning person. So I get up early, I do my best work on the elliptical; the computer perches just perfectly the laptop on the elliptical.
[00:03:35] Christine Ko: Yeah, all that is really good advice. Thank you. My next main question is - have you encountered failure and how do you process it?
[00:03:44] Dirk Elston: We've all encountered failure many times. Somewhere, someone told me: wise man once said, wisdom is the sum of our many failures. We learn more from our failures than from our successes. Just being honest with yourself, it wasn't the other guy's fault necessarily. What didn't go well; what could I have done differently? It's often a two-way street, you know, you're not the only one who contributed and there are often factors beyond your control, but some of it is deciding what things are worth pursuing and what things really are beyond your control.
[00:04:19] Christine Ko: I think failure, it's in some ways easiest to see with dermpath slides since they're static.
[00:04:27] Dirk Elston: Go back and look at it. That's actually brilliant because that's a perfect example of where you can go back and everything you had before: do you process it differently this time? Do you do something different this time? And I think we've all faced that as dermatopathologist, right? Wayne White used to refer to as unsolicited follow up information on a patient: was there something I missed? Was it just clinical setting? Or was it sampling that this really wasn't representative of the process? Be really honest with yourself, which it was, or you're gonna go down the same path again.
[00:05:01] Christine Ko: Do you have an approach or a way of acceptance of the subjectivity involved in things where there's no gold standard kind of other than our pathology diagnosis or a given expert's diagnosis?
[00:05:17] Dirk Elston: A few approaches. So one thing is I try not to bias myself going into a case. So first thing I do. Look at the glass blind to the history, then I'm definitely gonna look at the history to make sure I've answered the clinician's question. The other thing is, you know, we do a, as many groups do, we do a daily consensus conference where people look at it and, we're sort of informal, but there's always that possibility of the loudest voice in the room or the most respected most senior voice in the room. Something that Bill Tyler introduced years ago at Geisinger, we have dry erase boards. Hmm. And we have a case that, you know, there may really be subjectivity here. There may be a difference of opinion, and you really wanna get into everyone's head and say, how did they come to their thought and not have, especially those who are younger, be reticent to say anything because well, someone more senior thought something different, so they're not gonna speak up. So we designate something's a board case, and the dry erase boards go around and no one's allowed to speak, and you write down your thoughts and then everyone holds 'em up, and it really is enlightening. It's a nice way to bypass some of the societal things that are ingrained; we respect our elders, we respect our teachers. The last thing we're doing is we look at things where we have criteria and the criteria aren't necessarily defined; we look at a large number of cases and see how it plays out, what things are independently predictive.
[00:07:00] Christine Ko: I love that answer; it sort of segues into the next question, which I wanted to ask you if you have a diagnostic process, sort of a metacognitive process when you approach each slide, and sounds like you sort of already touched on that: you look at it first blindly without knowing the history, on the requisition and then...
[00:07:18] Dirk Elston: It's a gestalt, right? It's like, recognizing your sister, you don't say, well, you know, two eyes, a nose, a mouth; you just look at her and you know, it's your sister. If she were to dye her hair, it's still your sister, you'd say, Hey, you did something to your hair, but you still recognize her.
[00:07:36] Christine Ko: Yeah.
[00:07:37] Dirk Elston: Then there's the translating it for the students. Okay. How did you arrive at that? And that helps you put it into words for yourself. Because portions of it are really subconscious; they're reflexive and it makes you better when you have to put them into words. The last scenario is when you look at it, and you draw a blank.
[00:08:00] Christine Ko: Yeah.
[00:08:01] Dirk Elston: Right. Where I see all kinds of stuff, but it's not gelling as a diagnosis. Now I'm gonna look at the clinical question and look back at it. Okay. Now, does that make sense, given that? What steps do I need to get? Is it, do I need lab testing? Do I need more clinical? Do I need IHC? You know, what, what do I need to do now to, to get to a useful answer? Cuz there's someone waiting for an answer on the other other end.
[00:08:31] Christine Ko: Do you think that as with experience as you've become more and more senior in derm and dermpath, the instances where you put the slide up and you just, you draw blank, does that decrease with times?
[00:08:44] Oh, it thankfully thankfully, yes. It becomes less and less common. But, those things still occur and then what really helps us now is in so many of these cases, we have a clinical image.
[00:09:04] Electronically. Even when it's an outside case, you know, more and more people send images with it and it just makes it so much easier to, to put it together. And at least, you know, we're, we're a team where, where do we go next here? Yeah. I mean, they understand if it's confusing clinically. It may not be straightforward histologically.
[00:09:27] It sounds like your diagnostic process does relate to metacognition. When you said it's gestalt, that's like sort of thinking fast and just taking it all in and then the slow analytical, for example, like when we don't know right away, what something is, but also once you have a gestalt to check with the clinical to make sure you're answering the question that's presented, et cetera. You touched on bias a little bit earlier, and I know you've written a fair amount on bias as well. What do you think every doctor and patient should know about bias?
[00:09:56] Dirk Elston: That it is innate. It's something that's useful. We could not function in a world where we perceived everything, right? The buzzing in the background, the fly going by; I mean, you couldn't get your work done. You couldn't function. So you filter out things. And much of it comes with maturity of the brain. Young children hear every sound and every language in the world. As you develop your own language, you extinguish the ability to hear those other sounds, cuz they're not relevant. And we do that with all sorts of things where you filter out, what's not relevant. So you can see, you know, the tree for the forest.
[00:10:38] Christine Ko: Yeah.
[00:10:39] Dirk Elston: But you gotta be sure you're not missing the forest for the trees. What did you filter out? The key thing that you should have seen, and that's where bias comes in. Right. You know, most commonly in a medical set setting, cognitive bias, where you just filtered it out, because your brain considered it not relevant to the question at hand sometimes it's because we bias ourselves by looking at the history first.
[00:11:04] Christine Ko: Right.
Dirk Elston: You know, they're looking for a pigmented lesion. So I wasn't really paying that much attention to the lymphocytes. Right. You know, it could be that simple or they were looking for a pigmented lesion. So I really wasn't thinking it could be from lupus. Biasing ourselves with history, you know, that first objective look can bypass some of that.
[00:11:26] Yeah.
[00:11:26] Dirk Elston: But also being willing to go back and look again.
[00:11:29] Christine Ko: That's true. Sort of an unbiased unfiltered approach sometimes works best. Is there any lesson that you wished you had learned earlier?
[00:11:39] Dirk Elston: Patience is one. One of the best lessons I ever learned was from someone who left medicine because you know her. It just her life was not working. The kids were unhappy. She was unhappy. Her husband was unhappy and she hung it up and they lived on his income and she took care of the kids until they were off to school and more independent. And then she picked up practice again. And she was so much better just as a physician coming back, she was having more fun. And so I learned two things. One is: the taking time for yourself, because I think I was always the worst at that. The second was reinventing yourself is okay. Change is okay. Big changes are a little bit intimidating, but change can be a good thing.
[00:12:35] Christine Ko: Do you have any final thoughts?
[00:12:37] Dirk Elston: Just that there's no one right answer in life, you know, on a slide that's basal cell or not, there's probably one right answer, but choices in life there's no right answer. They're just different. It's not the destination. It's the journey.
[00:12:52] Christine Ko: Thank you so much for talking to me. I've known you since I was a resident, actually. I didn't say this before, but Dirk came and interviewed at UC Irvine when I was a resident to be Chairman and me and all of the rest of the residents: we wanted Dirk Elston to come; he was our top choice; of course, we didn't have the power to make that decision. I've known you since then and you've had such a big influence on me throughout, from then to now. So thank you.
[00:13:19] Dirk Elston: And vice versa. I mean, I, I always learn as much. I think I get as much as I give and working with you has always been a pleasure, so thank you.
[00:13:30] Christine Ko: Thank you.