1 00:00:03,880 --> 00:00:18,520 Speaker 1: Ruby our guest today. 2 00:00:18,600 --> 00:00:22,520 Speaker 2: Doctor Anna Shacone is a board certified dermatologist who runs 3 00:00:22,520 --> 00:00:26,439 Speaker 2: her own practice. She writes extensively about skin health and 4 00:00:26,560 --> 00:00:29,800 Speaker 2: access to care, and has built a social media platform 5 00:00:29,840 --> 00:00:34,840 Speaker 2: dedicated to reaching patients who are underserved in the dermatologic system. 6 00:00:35,360 --> 00:00:38,199 Speaker 2: She shows up where they are and in the language 7 00:00:38,200 --> 00:00:41,280 Speaker 2: they speak, because that's right. She is available to provide 8 00:00:41,280 --> 00:00:45,040 Speaker 2: care in multiple languages. What does it actually take to 9 00:00:45,159 --> 00:00:48,159 Speaker 2: make the most of a dermatology appointment? What do you 10 00:00:48,240 --> 00:00:50,960 Speaker 2: need to know going in? What do you as a 11 00:00:51,000 --> 00:00:53,880 Speaker 2: patient need to say? And how do we get past 12 00:00:53,920 --> 00:00:55,920 Speaker 2: the fact that saying what we need to say to 13 00:00:56,000 --> 00:01:00,960 Speaker 2: a doctor can sometimes feel really embarrassing or vulnerable. Doctor 14 00:01:01,040 --> 00:01:03,600 Speaker 2: Chacone has thought long and hard about all of this, 15 00:01:03,760 --> 00:01:06,080 Speaker 2: and I am so excited to talk to her today. 16 00:01:08,280 --> 00:01:11,240 Speaker 2: Doctor Anna Jaccone, Welcome to our Skin. We are so 17 00:01:11,400 --> 00:01:12,160 Speaker 2: glad you're here. 18 00:01:12,720 --> 00:01:15,000 Speaker 3: Thank you so much. I'm really honored to be here. 19 00:01:15,080 --> 00:01:16,200 Speaker 3: Thank you for inviting me. 20 00:01:16,840 --> 00:01:19,880 Speaker 2: And you mentioned before the show that you sometimes go 21 00:01:19,920 --> 00:01:22,920 Speaker 2: by doctor Anna. Is it okay if I call you that? Yeah? 22 00:01:22,920 --> 00:01:26,520 Speaker 2: Of course, terrific, Doctor Anna. I want to start with 23 00:01:26,560 --> 00:01:29,959 Speaker 2: your own story. What drew you to medicine? In the 24 00:01:30,000 --> 00:01:33,399 Speaker 2: first place. And then what made you choose dermatology as 25 00:01:33,440 --> 00:01:34,160 Speaker 2: your specialty. 26 00:01:34,640 --> 00:01:38,399 Speaker 3: Yeah, I was always drawn to medicine. My dad is 27 00:01:38,440 --> 00:01:41,840 Speaker 3: a physician. He's a doctor and was pretty immersed in it. 28 00:01:42,080 --> 00:01:46,840 Speaker 3: He does critical care, so intensive care, very critically ill patients, 29 00:01:47,160 --> 00:01:50,960 Speaker 3: life or death cases, and so we lived actually within 30 00:01:51,040 --> 00:01:54,160 Speaker 3: walking distance from one of the major hospitals here in 31 00:01:54,200 --> 00:01:57,000 Speaker 3: South Florida. It was just a big part of my life. 32 00:01:57,240 --> 00:01:59,320 Speaker 3: So it was just something I grew up with. He's 33 00:01:59,360 --> 00:02:02,480 Speaker 3: not a dreamtalklogists, and I'm the only dermatologist in my family. 34 00:02:02,800 --> 00:02:06,400 Speaker 3: I really enjoyed it. It's very visual. I liked reading 35 00:02:06,440 --> 00:02:09,360 Speaker 3: atlases and it just kind of came naturally to me. 36 00:02:09,639 --> 00:02:12,680 Speaker 3: And so it was actually a big point of contention 37 00:02:12,919 --> 00:02:15,480 Speaker 3: with my family. And it was actually really hard for 38 00:02:15,520 --> 00:02:17,600 Speaker 3: me to get into dermatology. I didn't match for the 39 00:02:17,639 --> 00:02:21,560 Speaker 3: first year. I did a whole year of unpaid research 40 00:02:21,680 --> 00:02:24,160 Speaker 3: to be able to get in, which is common because 41 00:02:24,160 --> 00:02:26,119 Speaker 3: it's a very hard feel to get into. I think 42 00:02:26,160 --> 00:02:30,160 Speaker 3: worldwide it's common for people to struggle to get in 43 00:02:30,360 --> 00:02:32,959 Speaker 3: for a while, and so I definitely did struggle and 44 00:02:33,120 --> 00:02:35,639 Speaker 3: my family was not happy about that. They were like, well, 45 00:02:35,680 --> 00:02:38,519 Speaker 3: you went to Brown. You kind of invested a lot 46 00:02:38,560 --> 00:02:40,680 Speaker 3: in you, You invested a lot in yourself. Why are 47 00:02:40,680 --> 00:02:42,359 Speaker 3: you not kind of making it? 48 00:02:42,520 --> 00:02:42,760 Speaker 2: You know? 49 00:02:43,320 --> 00:02:47,360 Speaker 3: And so I continued to just persist and try and 50 00:02:47,480 --> 00:02:48,280 Speaker 3: finally made it. 51 00:02:48,760 --> 00:02:51,200 Speaker 2: We're certainly glad you did because that benefits a lot 52 00:02:51,240 --> 00:02:54,000 Speaker 2: of people. And speaking of the people you benefit, I 53 00:02:54,240 --> 00:02:57,720 Speaker 2: want to talk today about patients advocating for ourselves in 54 00:02:57,840 --> 00:03:01,760 Speaker 2: doctor's appointments, which is not easy. You know, patients often 55 00:03:01,880 --> 00:03:04,400 Speaker 2: leave without asking what they wanted to ask. I know 56 00:03:04,440 --> 00:03:07,200 Speaker 2: that's happened to me, or they don't know how to 57 00:03:07,280 --> 00:03:10,640 Speaker 2: describe what they're experiencing, and they maybe feel foolish not 58 00:03:10,720 --> 00:03:13,200 Speaker 2: knowing the right terms, or they're afraid to push back 59 00:03:13,240 --> 00:03:15,880 Speaker 2: when they get an answer that they don't understand. What 60 00:03:15,919 --> 00:03:19,000 Speaker 2: do you wish that patients knew before they walked into 61 00:03:19,080 --> 00:03:20,320 Speaker 2: a dermatology appointment? 62 00:03:20,880 --> 00:03:25,520 Speaker 3: I would say definitely that it's confidential and at least 63 00:03:25,600 --> 00:03:28,239 Speaker 3: for me and a lot of the doctors I work with, 64 00:03:28,600 --> 00:03:31,120 Speaker 3: and that I know that we're just trying our best. 65 00:03:31,160 --> 00:03:34,320 Speaker 3: And also, when you choose a doctor, not everyone is 66 00:03:34,440 --> 00:03:37,320 Speaker 3: the same. So you might have had a bad experience 67 00:03:37,360 --> 00:03:40,160 Speaker 3: with one doctor. But you know, although we have standards 68 00:03:40,160 --> 00:03:43,760 Speaker 3: of care. Your experience is going to be always different. 69 00:03:44,040 --> 00:03:47,880 Speaker 3: So when you choose a doctor, you're kind of choosing 70 00:03:47,880 --> 00:03:51,560 Speaker 3: that individual based on their background, their specialty, what they 71 00:03:51,600 --> 00:03:54,200 Speaker 3: focus on, what they train in, maybe if you have 72 00:03:54,320 --> 00:03:58,080 Speaker 3: common interest, maybe if a friend or a family member 73 00:03:58,080 --> 00:04:00,560 Speaker 3: had a good experience with them, or if they were 74 00:04:00,560 --> 00:04:04,280 Speaker 3: involved in clinical trials or so. Everyone is actually different, 75 00:04:04,680 --> 00:04:07,800 Speaker 3: and to not let just want experience kind of steer 76 00:04:07,840 --> 00:04:10,760 Speaker 3: you in a positive or negative direction, you know. 77 00:04:11,480 --> 00:04:14,160 Speaker 2: And then what prep work do you just love to 78 00:04:14,200 --> 00:04:16,760 Speaker 2: see a patient do before they see you? What are 79 00:04:16,880 --> 00:04:19,839 Speaker 2: questions that you wish every patient would ask. 80 00:04:20,520 --> 00:04:23,800 Speaker 3: One thing I've actually started to do myself, which I 81 00:04:23,920 --> 00:04:26,960 Speaker 3: find very helpful is writing a to do list, though 82 00:04:27,000 --> 00:04:30,239 Speaker 3: I do have patients that outline a body on piece 83 00:04:30,279 --> 00:04:33,400 Speaker 3: of paper and put kind of x's or dots and 84 00:04:33,760 --> 00:04:36,880 Speaker 3: little offshoots of okay, well there's a pimple here and 85 00:04:37,000 --> 00:04:39,680 Speaker 3: this is not going way on the back. I actually 86 00:04:40,160 --> 00:04:44,360 Speaker 3: have started to appreciate those notes more because it streamlines 87 00:04:44,760 --> 00:04:48,120 Speaker 3: the visit, and I like to go over those notes 88 00:04:48,160 --> 00:04:51,120 Speaker 3: first and then kind of see if there's any questions. 89 00:04:51,360 --> 00:04:55,000 Speaker 3: It's hard when there's sometimes no focus in the visit 90 00:04:55,360 --> 00:04:57,880 Speaker 3: or someone may not know why they're there. Let's say 91 00:04:57,880 --> 00:04:59,880 Speaker 3: they were referred by the primary and then they get 92 00:04:59,880 --> 00:05:02,240 Speaker 3: the and what am I doing here? And I found 93 00:05:02,279 --> 00:05:04,880 Speaker 3: it to be helpful myself when I go to the doctor, 94 00:05:04,920 --> 00:05:07,599 Speaker 3: I actually do that now, write a to do list, 95 00:05:07,839 --> 00:05:10,120 Speaker 3: because sometimes there is stuff I just have to go 96 00:05:10,160 --> 00:05:12,839 Speaker 3: over and if I don't write it down, I don't remember. 97 00:05:13,560 --> 00:05:16,640 Speaker 2: I also want to talk about the emotional component of it, 98 00:05:16,720 --> 00:05:19,760 Speaker 2: because dermatology appointments can be very emotional for a lot 99 00:05:19,800 --> 00:05:22,839 Speaker 2: of people. Any doctor's appointment can, but in this case, 100 00:05:22,880 --> 00:05:26,479 Speaker 2: you're talking often about the visible part of yourself, and 101 00:05:26,800 --> 00:05:31,040 Speaker 2: appearance can trigger so many personal feelings and just make 102 00:05:31,080 --> 00:05:34,200 Speaker 2: people a little bit stressed and feel very vulnerable. So 103 00:05:34,640 --> 00:05:36,719 Speaker 2: what do you do to put patients at ease in 104 00:05:36,760 --> 00:05:37,480 Speaker 2: that situation? 105 00:05:38,120 --> 00:05:42,880 Speaker 3: So that's a great question. First, just normalizing it. There's 106 00:05:42,920 --> 00:05:46,279 Speaker 3: nothing I haven't seen at this point. So you know, 107 00:05:46,440 --> 00:05:50,760 Speaker 3: we have had patients really embarrassed about things like genital awards, 108 00:05:50,800 --> 00:05:54,359 Speaker 3: and it's of course I've seen thousands of those. Everything 109 00:05:54,400 --> 00:05:57,719 Speaker 3: is normal. That basically happens in the visit. The other 110 00:05:57,760 --> 00:05:59,960 Speaker 3: thing I do is I always go with a medical 111 00:06:00,120 --> 00:06:04,440 Speaker 3: assistant to kind of diffuse any tension. They're free to 112 00:06:05,120 --> 00:06:08,359 Speaker 3: bring somebody if they want. We also have a water 113 00:06:08,520 --> 00:06:12,000 Speaker 3: machine that diffuses noise. I actually picked it up from 114 00:06:12,000 --> 00:06:14,880 Speaker 3: another hospital. I thought that was a good idea. But 115 00:06:14,960 --> 00:06:18,880 Speaker 3: it's relaxing. But it also doesn't let you hear what's 116 00:06:18,920 --> 00:06:22,800 Speaker 3: happening in the rooms next door, so we create a 117 00:06:22,839 --> 00:06:27,320 Speaker 3: non judgmental environment. Just listen. Usually I just let patients 118 00:06:27,360 --> 00:06:31,840 Speaker 3: talk basically, tell nothing's surprising or inappropriate. They can just 119 00:06:31,880 --> 00:06:32,720 Speaker 3: bring anything up. 120 00:06:33,600 --> 00:06:37,760 Speaker 2: Are there any other tips that you have for people 121 00:06:37,800 --> 00:06:40,640 Speaker 2: who might be feeling too embarrassed to even start the 122 00:06:40,680 --> 00:06:42,280 Speaker 2: conversation about their skin. 123 00:06:43,080 --> 00:06:45,840 Speaker 3: I would say, if they're a little too embarrassed, at 124 00:06:45,839 --> 00:06:48,080 Speaker 3: the very least, I try to do a full skin check. 125 00:06:48,800 --> 00:06:51,400 Speaker 3: And I also tell them, especially because I see a 126 00:06:51,440 --> 00:06:54,800 Speaker 3: lot of patients online and on weekends and I don't 127 00:06:54,839 --> 00:06:57,400 Speaker 3: take a lot of time off, that they can always 128 00:06:57,480 --> 00:07:00,880 Speaker 3: come back and discuss that. So if they don't feel 129 00:07:00,880 --> 00:07:04,000 Speaker 3: like they're able to discuss it that day, that's fine. 130 00:07:04,120 --> 00:07:07,200 Speaker 3: And I myself have had you know, doctor's appointments or 131 00:07:07,240 --> 00:07:10,040 Speaker 3: doctors where I actually sometimes wait a long time to 132 00:07:10,040 --> 00:07:13,760 Speaker 3: tell them things that matter. Unfortunately, trust has to build, 133 00:07:13,800 --> 00:07:16,400 Speaker 3: and it's you're not going to sometimes build that trust 134 00:07:16,400 --> 00:07:18,760 Speaker 3: from the beginning or gain that trust from a patient. 135 00:07:19,600 --> 00:07:22,000 Speaker 2: It's reassuring to know that even you, as a doctor, 136 00:07:22,120 --> 00:07:25,440 Speaker 2: need to build that trust with your physicians. I also 137 00:07:25,480 --> 00:07:28,840 Speaker 2: do want to talk some more about the physician side 138 00:07:28,880 --> 00:07:32,720 Speaker 2: of the equation. What do you wish that dermatologists did better? 139 00:07:32,880 --> 00:07:35,240 Speaker 2: Because if we're being really honest, the system is not 140 00:07:35,520 --> 00:07:38,720 Speaker 2: always great. Not every physician is wonderful at meeting a 141 00:07:38,760 --> 00:07:39,720 Speaker 2: patient where they are. 142 00:07:40,360 --> 00:07:44,080 Speaker 3: There's many things that doctors can do better, dermatologists included. 143 00:07:44,400 --> 00:07:48,280 Speaker 3: But sometimes we're constrained. Like you know, having my own practice, 144 00:07:48,320 --> 00:07:51,040 Speaker 3: I would say the insurance part is just horrendous to 145 00:07:51,080 --> 00:07:55,200 Speaker 3: deal with. It forces you to spend less time with patients, 146 00:07:55,240 --> 00:07:58,920 Speaker 3: and it's common for them not to reimburse more than 147 00:07:58,920 --> 00:08:01,480 Speaker 3: a certain amount of time. I would say I have 148 00:08:01,600 --> 00:08:04,160 Speaker 3: worked at practices or been in settings where you have 149 00:08:04,240 --> 00:08:08,680 Speaker 3: to be really fast or efficient, and that can make 150 00:08:09,160 --> 00:08:12,240 Speaker 3: a patient not feel fully heard. And what I do 151 00:08:12,280 --> 00:08:15,440 Speaker 3: in those cases, what I'm constrained with time is that 152 00:08:15,560 --> 00:08:17,840 Speaker 3: I just try to open up more time in the 153 00:08:17,920 --> 00:08:21,000 Speaker 3: schedule or tell them, you know, we have to divide 154 00:08:21,000 --> 00:08:24,040 Speaker 3: this visit. You know, we can address this today and 155 00:08:24,040 --> 00:08:25,640 Speaker 3: then you're going to have to come back next week 156 00:08:25,720 --> 00:08:28,120 Speaker 3: or next month to address the other half and then 157 00:08:28,920 --> 00:08:32,480 Speaker 3: kind of setting an agenda like I was talking about 158 00:08:32,480 --> 00:08:34,440 Speaker 3: with the to do list of things that are kind 159 00:08:34,440 --> 00:08:38,760 Speaker 3: of more important and then leaving the things that could 160 00:08:38,800 --> 00:08:41,360 Speaker 3: be addressed later. But yeah, I would say time is 161 00:08:41,440 --> 00:08:43,800 Speaker 3: the biggest. Feels like it's not on our side. 162 00:08:43,840 --> 00:08:48,320 Speaker 2: Sometimes. You have also written and spoken about access to 163 00:08:48,360 --> 00:08:53,400 Speaker 2: dermatologic care. It is not evenly distributed. Certain communities have 164 00:08:53,559 --> 00:08:56,480 Speaker 2: a much harder time getting to see a specialist. What 165 00:08:56,520 --> 00:08:59,240 Speaker 2: does that look like in practice and in your opinion, 166 00:08:59,280 --> 00:09:00,920 Speaker 2: what is that actually costing people? 167 00:09:01,600 --> 00:09:04,880 Speaker 3: Yeah, So I've worked at a lot of different places, 168 00:09:05,000 --> 00:09:07,240 Speaker 3: you know, because I do work in all fifty states. 169 00:09:07,280 --> 00:09:10,600 Speaker 3: I have an idea of what access looks like, you know, 170 00:09:10,800 --> 00:09:13,200 Speaker 3: all all over the country. And I would say it's 171 00:09:13,320 --> 00:09:18,679 Speaker 3: easier in urban centers, some suburban centers to get a dermatologist. 172 00:09:18,800 --> 00:09:22,760 Speaker 3: I go out to New Mexico to a Novajo clinic 173 00:09:22,800 --> 00:09:26,120 Speaker 3: there where they never had a dermatologist. In New Mexico. 174 00:09:26,200 --> 00:09:28,559 Speaker 3: The whole state of New Mexico has like a huge 175 00:09:28,720 --> 00:09:32,000 Speaker 3: limited access to specialists. It's really hard to be seen 176 00:09:32,040 --> 00:09:36,360 Speaker 3: there by a dermatologist, and almost any specialist. A lot 177 00:09:36,360 --> 00:09:40,640 Speaker 3: of the population is rural Alaska too. I also work 178 00:09:40,679 --> 00:09:44,160 Speaker 3: in rural Alaska. It's hard to be seen. I think 179 00:09:44,160 --> 00:09:45,920 Speaker 3: the wait list is like a year and a half. 180 00:09:46,240 --> 00:09:50,320 Speaker 3: I think some things that can help our things like 181 00:09:50,400 --> 00:09:53,800 Speaker 3: online booking, which we have and actually both these other 182 00:09:53,880 --> 00:09:56,319 Speaker 3: places don't have. You know, there's a lot that can 183 00:09:56,400 --> 00:09:58,960 Speaker 3: happen in a year and a half to have somebody wait, 184 00:09:59,240 --> 00:10:02,400 Speaker 3: and I don't see how it's not a liability for anyone, 185 00:10:02,640 --> 00:10:05,800 Speaker 3: you know, or an institution to have people waiting that long. 186 00:10:06,120 --> 00:10:08,760 Speaker 3: I assume it's kind of a funding issue as well. 187 00:10:09,000 --> 00:10:12,840 Speaker 3: For certain clinics, like let's say the Navajo there it's 188 00:10:12,920 --> 00:10:15,040 Speaker 3: unclear kind of where they get their funding. We know 189 00:10:15,160 --> 00:10:18,960 Speaker 3: that IHS doesn't have a lot of funding period and 190 00:10:19,040 --> 00:10:21,400 Speaker 3: much less for specialists. So that's why a lot of 191 00:10:21,640 --> 00:10:24,360 Speaker 3: Native clinics there's like a number that they applied for 192 00:10:24,600 --> 00:10:27,160 Speaker 3: where they kind of turn their clinic into almost like 193 00:10:27,200 --> 00:10:29,760 Speaker 3: a private practice, so it doesn't have to be as 194 00:10:29,800 --> 00:10:31,880 Speaker 3: dependent on that sort of funding. 195 00:10:32,880 --> 00:10:35,800 Speaker 2: You also use your social media in a really really 196 00:10:35,840 --> 00:10:38,880 Speaker 2: deliberate way, and you have built a practice that actually 197 00:10:39,320 --> 00:10:44,120 Speaker 2: emphasizes telemedicine and its benefits. What drove you to that 198 00:10:44,240 --> 00:10:46,800 Speaker 2: decision and what have you learned in the process of 199 00:10:46,880 --> 00:10:50,600 Speaker 2: running a telehealth practice what people actually need? 200 00:10:51,320 --> 00:10:54,880 Speaker 3: So telehealth really, you know, it boomed, I would say, 201 00:10:55,040 --> 00:10:57,480 Speaker 3: with COVID, and that's when I really got into it. 202 00:10:57,840 --> 00:11:00,520 Speaker 3: I got into it for various reasons. I was at 203 00:11:00,520 --> 00:11:04,160 Speaker 3: Cleveland Clinic at that time, and it was all around 204 00:11:04,200 --> 00:11:07,440 Speaker 3: me pretty much. Doctors were losing their jobs, like a 205 00:11:07,480 --> 00:11:11,040 Speaker 3: lot of dermatologists were furloughed. Anything that was deemed non 206 00:11:11,160 --> 00:11:14,600 Speaker 3: essential was pretty much shut down. And then I also 207 00:11:14,679 --> 00:11:19,120 Speaker 3: saw some doctors' careers just crash because they weren't built 208 00:11:19,480 --> 00:11:22,320 Speaker 3: to work remotely. And I don't know how this kind 209 00:11:22,320 --> 00:11:25,520 Speaker 3: of didn't happen sooner, because you know, as I was mentioning, 210 00:11:25,559 --> 00:11:28,840 Speaker 3: we deal with a lot of natural disasters like hurricanes, 211 00:11:29,040 --> 00:11:31,440 Speaker 3: so you kind of have to have a way to 212 00:11:31,520 --> 00:11:33,959 Speaker 3: make a living, not just make a living, but give 213 00:11:34,000 --> 00:11:37,040 Speaker 3: your staff a living and also still take care of patients. 214 00:11:37,360 --> 00:11:39,719 Speaker 3: I think the best approach, what I learned for me 215 00:11:40,120 --> 00:11:42,560 Speaker 3: and what I think works for patients is hybrid, like 216 00:11:42,600 --> 00:11:46,119 Speaker 3: a hybrid system where if you don't need a procedure, 217 00:11:46,280 --> 00:11:49,120 Speaker 3: or you just need to talk, or you need a 218 00:11:49,200 --> 00:11:52,640 Speaker 3: change in medication or something that just doesn't require a 219 00:11:52,720 --> 00:11:56,520 Speaker 3: hands on examination. You can address it virtually, and so 220 00:11:56,600 --> 00:11:59,680 Speaker 3: I like having that approach. I found that patients like 221 00:12:00,360 --> 00:12:01,319 Speaker 3: both things. 222 00:12:01,640 --> 00:12:04,040 Speaker 2: I love it. I mean I have loved the switch 223 00:12:04,080 --> 00:12:07,120 Speaker 2: to tell amedicine as an option. You know, when I'm like, hey, 224 00:12:07,120 --> 00:12:09,199 Speaker 2: I got a rash doing work in the yard. Can 225 00:12:09,240 --> 00:12:11,320 Speaker 2: I get a green for this? I don't have to 226 00:12:11,320 --> 00:12:14,000 Speaker 2: go through the whole appointment process. I also want to 227 00:12:14,000 --> 00:12:18,160 Speaker 2: talk about the research that's happened on psoriasis, because historically 228 00:12:18,240 --> 00:12:22,880 Speaker 2: it has centered on certain populations and largely or completely 229 00:12:22,960 --> 00:12:25,880 Speaker 2: ignored others. We're going to talk about all of that today, 230 00:12:26,320 --> 00:12:30,320 Speaker 2: but as someone who thinks about representation in medicine, where 231 00:12:30,360 --> 00:12:33,040 Speaker 2: do you see the gaps? What is really getting missed? 232 00:12:34,000 --> 00:12:38,319 Speaker 3: I would say that there's a lot of research in biologics. 233 00:12:38,360 --> 00:12:41,720 Speaker 3: I want to say medications that are expensive. You know, 234 00:12:41,800 --> 00:12:44,000 Speaker 3: we've come up with a lot of great treatments for 235 00:12:44,080 --> 00:12:48,000 Speaker 3: psoriasis and eczema and even hydratonitis, but there needs to 236 00:12:48,040 --> 00:12:52,080 Speaker 3: be more innovation. Still with psoriasis, we've probably made the 237 00:12:52,160 --> 00:12:55,760 Speaker 3: most strides because now we can, you know, tackle things 238 00:12:55,800 --> 00:12:59,960 Speaker 3: like arthritis which you couldn't do before biologics very effective. 239 00:13:00,679 --> 00:13:04,640 Speaker 3: The other thing is a representation of different skin types 240 00:13:04,679 --> 00:13:08,679 Speaker 3: and populations is important because it can lead to mister 241 00:13:08,800 --> 00:13:13,840 Speaker 3: delayed diagnosis unless tailored treatment approaches. And trying to just 242 00:13:13,960 --> 00:13:18,199 Speaker 3: include variety in research and education is important, and also 243 00:13:18,520 --> 00:13:22,199 Speaker 3: including doctors in private practice. I find that with research 244 00:13:22,440 --> 00:13:25,080 Speaker 3: they tend to include a lot of people who are 245 00:13:25,320 --> 00:13:29,200 Speaker 3: in academics, not so much the people who are in 246 00:13:29,240 --> 00:13:30,080 Speaker 3: private practice. 247 00:13:31,080 --> 00:13:33,160 Speaker 2: Doctor Anna, I want to close out this segment by 248 00:13:33,200 --> 00:13:36,839 Speaker 2: talking about what might be coming next for you. Are 249 00:13:36,880 --> 00:13:40,440 Speaker 2: there any projects or initiatives that you're really excited about? 250 00:13:40,880 --> 00:13:42,000 Speaker 4: So, yeah, I wanted to. 251 00:13:42,640 --> 00:13:45,400 Speaker 3: I was working on an online course and I kind 252 00:13:45,440 --> 00:13:50,040 Speaker 3: of wanted it to be teledermatology related or dermatology related. 253 00:13:50,440 --> 00:13:53,880 Speaker 3: Because the AAD has a lot of resources, it's hard 254 00:13:53,920 --> 00:13:58,600 Speaker 3: to get a bridge between doctors and patients. Sometimes. I 255 00:13:58,640 --> 00:14:02,760 Speaker 3: have a podcast too, actually that I've had since last year. 256 00:14:03,160 --> 00:14:06,560 Speaker 3: We interview a lot of leaders, entrepreneurs, people that you 257 00:14:06,600 --> 00:14:07,679 Speaker 3: know are just interesting. 258 00:14:08,520 --> 00:14:10,160 Speaker 2: And what is the name of that podcast so we 259 00:14:10,200 --> 00:14:10,840 Speaker 2: can all know it? 260 00:14:11,160 --> 00:14:14,640 Speaker 3: Yeah, it's skin Deep. Ah, perfect, It's not the only 261 00:14:14,720 --> 00:14:18,520 Speaker 3: skin deep podcast there's there's actually quite a few, but yeah. 262 00:14:18,520 --> 00:14:23,080 Speaker 2: Look for doctor Anna's skin Deep. After the break, we 263 00:14:23,280 --> 00:14:25,400 Speaker 2: are going to talk about one of the reasons that 264 00:14:25,600 --> 00:14:30,040 Speaker 2: access to medical care can be so unequally distributed. For many, 265 00:14:30,120 --> 00:14:34,520 Speaker 2: many years, we had a quote unquote default patient used 266 00:14:34,560 --> 00:14:37,920 Speaker 2: in designing medical trials and research that shall we say, 267 00:14:38,040 --> 00:14:41,320 Speaker 2: did not quite capture a lot of the population, and 268 00:14:41,360 --> 00:14:45,280 Speaker 2: that caused some real issues. More about that after the break. 269 00:14:54,480 --> 00:14:56,960 Speaker 2: I want to tell you about a policy, doctor Anna, 270 00:14:57,160 --> 00:15:00,280 Speaker 2: and I also am very curious to hear your take 271 00:15:00,360 --> 00:15:01,800 Speaker 2: on all of this, so I'm going to ask you 272 00:15:01,840 --> 00:15:05,080 Speaker 2: some questions as we go. In nineteen seventy seven, the 273 00:15:05,120 --> 00:15:09,280 Speaker 2: Food and Drug Administration issued guidance recommending that women of 274 00:15:09,480 --> 00:15:13,800 Speaker 2: childbearing potential be excluded from phase one and phase two 275 00:15:13,840 --> 00:15:17,920 Speaker 2: clinical trials. Phase one and phase two. As doctor Anninos, 276 00:15:18,000 --> 00:15:20,920 Speaker 2: but our listeners may not are the earliest stages of 277 00:15:21,000 --> 00:15:25,640 Speaker 2: human drug testing. They're where researchers establish safety and dosing. 278 00:15:26,040 --> 00:15:28,640 Speaker 2: They are where the foundational data about how a drug 279 00:15:28,720 --> 00:15:32,400 Speaker 2: behaves in a human body gets collected. And that guidance 280 00:15:32,480 --> 00:15:36,200 Speaker 2: existed because of a real tragedy, and that is tholidamide, 281 00:15:36,360 --> 00:15:39,840 Speaker 2: the sedative that caused severe birth defects when taken during 282 00:15:39,880 --> 00:15:43,680 Speaker 2: pregnancy in the late nineteen fifties and early nineteen sixties. 283 00:15:44,080 --> 00:15:47,280 Speaker 2: It had made the FDA and the broader medical establishment 284 00:15:47,400 --> 00:15:51,160 Speaker 2: acutely aware of the risks of exposing pregnant women or 285 00:15:51,160 --> 00:15:55,720 Speaker 2: women who might become pregnant to experimental drugs. By the way, 286 00:15:56,160 --> 00:15:59,200 Speaker 2: just as a cool aside, the doctor at the FDA 287 00:15:59,280 --> 00:16:03,360 Speaker 2: who refused to certify the lidamide as safe even though 288 00:16:03,440 --> 00:16:07,000 Speaker 2: it was approved elsewhere and the pharmaceutical company put her 289 00:16:07,080 --> 00:16:11,480 Speaker 2: under immense pressure was an absolute badass named doctor Francis Kelsey. 290 00:16:11,960 --> 00:16:15,240 Speaker 2: She because of that decision, saved a lot of babies. 291 00:16:15,680 --> 00:16:19,240 Speaker 2: So this exclusion of women from clinical trials didn't really 292 00:16:19,320 --> 00:16:23,440 Speaker 2: come from ill intentions, but it has caused serious problems 293 00:16:23,600 --> 00:16:26,360 Speaker 2: and those who have been playing out ever since, because 294 00:16:26,680 --> 00:16:30,400 Speaker 2: what happens when you build your entire early stage knowledge 295 00:16:30,440 --> 00:16:34,040 Speaker 2: base about a drug safety and dosing on male bodies 296 00:16:34,160 --> 00:16:37,200 Speaker 2: and then prescribed that drug to female bodies is that 297 00:16:37,240 --> 00:16:41,200 Speaker 2: you eventually discover that that dosing is often wrong. Let's 298 00:16:41,240 --> 00:16:43,800 Speaker 2: talk about some specifics here. Keep in mind as we 299 00:16:43,880 --> 00:16:46,680 Speaker 2: go through this section that there are of course exceptions 300 00:16:46,880 --> 00:16:50,440 Speaker 2: to any conversation when we're talking about humans as a 301 00:16:50,480 --> 00:16:54,200 Speaker 2: simple binary of sexes, and as these examples show, working 302 00:16:54,240 --> 00:16:57,120 Speaker 2: off of a model of an average human of any 303 00:16:57,200 --> 00:17:00,440 Speaker 2: kind is going to be inherently flawed. So with that 304 00:17:00,480 --> 00:17:04,320 Speaker 2: out of the way, women metabolize many drugs more slowly 305 00:17:04,400 --> 00:17:07,600 Speaker 2: than men. Their bodies often have different proportions of fat 306 00:17:07,640 --> 00:17:10,920 Speaker 2: to muscle mass, and that affects how drugs are distributed. 307 00:17:11,359 --> 00:17:15,919 Speaker 2: Their hormonal fluctuations across the menstrual cycle with pregnancy, with 308 00:17:16,080 --> 00:17:20,080 Speaker 2: menopause can alter drug response in ways that were simply 309 00:17:20,119 --> 00:17:23,879 Speaker 2: not captured in studies that were conducted almost entirely on 310 00:17:24,040 --> 00:17:29,120 Speaker 2: men for decades. Physiological models in studies used a seventy 311 00:17:29,240 --> 00:17:32,360 Speaker 2: kilogram man that's about one hundred and fifty four pounds 312 00:17:32,520 --> 00:17:37,119 Speaker 2: as the assumed baseline. That was the reference body, That 313 00:17:37,400 --> 00:17:40,600 Speaker 2: was the body that dosing was designed for. That was 314 00:17:40,640 --> 00:17:44,000 Speaker 2: the body whose adverse events were measured and reported. So 315 00:17:44,680 --> 00:17:48,560 Speaker 2: not all that representative at all, Doctor Anna, I'm curious, 316 00:17:48,680 --> 00:17:50,919 Speaker 2: is this the sort of thing that you hear about 317 00:17:50,960 --> 00:17:54,120 Speaker 2: in medical school and if so, how does this history 318 00:17:54,240 --> 00:17:56,919 Speaker 2: get communicated to the next generation of doctors. 319 00:17:57,680 --> 00:17:59,600 Speaker 3: No, I had not heard about that, and I do 320 00:18:00,320 --> 00:18:04,800 Speaker 3: trials and practice. I'm actually doing too right now. That 321 00:18:04,920 --> 00:18:08,000 Speaker 3: isn't something I had heard of. Of course, the linimitis 322 00:18:08,000 --> 00:18:10,400 Speaker 3: been around for a very long time. I've used it 323 00:18:10,440 --> 00:18:13,920 Speaker 3: with certain connective tissue disorders that are just hard to treat. 324 00:18:13,960 --> 00:18:17,000 Speaker 3: It's a very good drug. It's unfortunate that it had 325 00:18:17,000 --> 00:18:20,320 Speaker 3: those side effects and that they weren't discovered till much later. 326 00:18:20,880 --> 00:18:23,760 Speaker 3: We don't go too much into research, so it wasn't 327 00:18:23,800 --> 00:18:27,280 Speaker 3: really emphasized a lot in certain workplaces. 328 00:18:27,840 --> 00:18:31,040 Speaker 2: That's fascinating to note that that's not an inherent part 329 00:18:31,080 --> 00:18:32,240 Speaker 2: of medical school. 330 00:18:32,560 --> 00:18:35,320 Speaker 3: We don't get into a lot of details, more like 331 00:18:35,400 --> 00:18:36,520 Speaker 3: the statistical part. 332 00:18:36,920 --> 00:18:39,679 Speaker 2: Right, Well, we're going to keep talking about the history 333 00:18:39,680 --> 00:18:43,000 Speaker 2: of it. So people were starting to notice that this 334 00:18:43,280 --> 00:18:47,520 Speaker 2: sort of imaginary sampleman was not actually representing how medicine 335 00:18:47,520 --> 00:18:51,720 Speaker 2: worked in a wider population. Pressure to broaden the research 336 00:18:51,800 --> 00:18:54,720 Speaker 2: lens had been buildings throughout the nineteen seventies and into 337 00:18:54,760 --> 00:18:58,880 Speaker 2: the nineteen eighties, from basically all directions from activists, from 338 00:18:58,960 --> 00:19:02,000 Speaker 2: doctors that were aware of the problem, from everyone really. 339 00:19:02,280 --> 00:19:05,480 Speaker 2: In nineteen eighty five, the US Public Health Service Task 340 00:19:05,560 --> 00:19:08,760 Speaker 2: Force on Women's Health released a report that said very 341 00:19:08,760 --> 00:19:12,359 Speaker 2: plainly that the exclusion of women from clinical research was 342 00:19:12,440 --> 00:19:16,840 Speaker 2: costing people their health. NIH responded in nineteen eighty six, 343 00:19:16,920 --> 00:19:21,480 Speaker 2: it established a policy encouraging researchers to include women in 344 00:19:21,560 --> 00:19:26,000 Speaker 2: federally funded studies. That policy was published in nineteen eighty seven. 345 00:19:26,320 --> 00:19:29,800 Speaker 2: In nineteen eighty nine, NIH went a step further, issuing 346 00:19:29,840 --> 00:19:33,600 Speaker 2: a memorandum that required researchers who wanted to exclude women 347 00:19:33,600 --> 00:19:37,360 Speaker 2: in minorities to at least justify that decision in writing 348 00:19:37,680 --> 00:19:41,439 Speaker 2: so on paper. By the late nineteen eighties, NIH was 349 00:19:41,800 --> 00:19:45,440 Speaker 2: on the right track. In nineteen ninety, the Congressional Caucus 350 00:19:45,480 --> 00:19:48,879 Speaker 2: for Women's Issues asked the General Accounting Office that is 351 00:19:48,920 --> 00:19:52,760 Speaker 2: now known as the Government Accountability Office to find out 352 00:19:52,800 --> 00:19:56,960 Speaker 2: whether any of this was actually happening, and the GAO's answer, 353 00:19:57,160 --> 00:20:00,639 Speaker 2: delivered in a nineteen ninety two report, was essentially no. 354 00:20:01,320 --> 00:20:04,800 Speaker 2: The policy had been very poorly communicated, it had been 355 00:20:04,880 --> 00:20:09,000 Speaker 2: applied inconsistently. It only covered research that was funded through 356 00:20:09,080 --> 00:20:14,600 Speaker 2: external grants, not the research conducted by NIH's own scientists. 357 00:20:15,040 --> 00:20:18,720 Speaker 2: Women were still being excluded from studies, or they were 358 00:20:18,840 --> 00:20:22,040 Speaker 2: enrolled in numbers that were so small that any data 359 00:20:22,240 --> 00:20:27,720 Speaker 2: about sex specific differences was statistically useless. The NIH Revitalization 360 00:20:27,920 --> 00:20:31,719 Speaker 2: Act of nineteen ninety three changed the legal landscape for 361 00:20:31,800 --> 00:20:35,080 Speaker 2: the first time. It was the law, not just guidance, 362 00:20:35,480 --> 00:20:40,159 Speaker 2: that NIH funded research must include women and minorities in 363 00:20:40,200 --> 00:20:45,359 Speaker 2: clinical trials, and that researchers must analyze results by sex 364 00:20:45,400 --> 00:20:49,240 Speaker 2: and by race, not just report aggregated outcomes as if 365 00:20:49,280 --> 00:20:52,359 Speaker 2: everyone were the same. This was a landmark, and it 366 00:20:52,440 --> 00:20:57,560 Speaker 2: was long overdue, But the downstream effects of systematically understudying 367 00:20:57,600 --> 00:21:01,840 Speaker 2: female physiology did not magic disappear in nineteen ninety three. 368 00:21:02,280 --> 00:21:05,240 Speaker 2: The knowledge gaps were real, and they still had to 369 00:21:05,280 --> 00:21:09,240 Speaker 2: be filled study by study, year by year, often against 370 00:21:09,320 --> 00:21:14,400 Speaker 2: institutional resistance. So here's what that has meant. Specifically for psyiasis, 371 00:21:14,880 --> 00:21:19,040 Speaker 2: research now shows that women and men experience psoriasis differently. 372 00:21:19,359 --> 00:21:23,040 Speaker 2: Women report higher rates of fatigue and worse quality of 373 00:21:23,080 --> 00:21:27,520 Speaker 2: life scores than men with equivalent disease. Severity, women are 374 00:21:27,560 --> 00:21:32,760 Speaker 2: more likely to experience certain presentations of soriatic arthritis. The disease, 375 00:21:33,320 --> 00:21:37,680 Speaker 2: of course, can be influenced by pregnancy, by hormonal contraception, 376 00:21:37,840 --> 00:21:41,160 Speaker 2: and by menopause, all of which create windows that mail 377 00:21:41,240 --> 00:21:45,440 Speaker 2: centered research frameworks were just not designed to study. Now, 378 00:21:45,800 --> 00:21:49,920 Speaker 2: some things have changed. The nineteen ninety three mandate catalyzed 379 00:21:50,000 --> 00:21:53,720 Speaker 2: a genuine shift in how clinical research is designed. The 380 00:21:53,760 --> 00:21:59,360 Speaker 2: FDA now requires sex disaggregation of trial datam Funding bodies 381 00:21:59,400 --> 00:22:03,840 Speaker 2: have developed specific programs for studying sex as a biological variable. 382 00:22:04,280 --> 00:22:07,680 Speaker 2: The gap in what we know is narrowing study by study, 383 00:22:08,160 --> 00:22:12,080 Speaker 2: but the dosing standards, the clinical guidelines, and the textbooks 384 00:22:12,119 --> 00:22:15,359 Speaker 2: were all built on male default for a very long time, 385 00:22:15,760 --> 00:22:20,200 Speaker 2: and medicine has a very long institutional memory. Those defaults 386 00:22:20,240 --> 00:22:24,199 Speaker 2: do not suddenly disappear just because the law changed. And 387 00:22:24,240 --> 00:22:26,960 Speaker 2: there is also a second gap that the nineteen ninety 388 00:22:26,960 --> 00:22:30,800 Speaker 2: three mandate addressed but did not solve, and that is race. 389 00:22:31,280 --> 00:22:34,920 Speaker 2: The same report that flagged the underrepresentation of women also 390 00:22:35,040 --> 00:22:40,160 Speaker 2: flagged the underrepresentation of racial and ethnic minorities in clinical research. 391 00:22:40,240 --> 00:22:44,800 Speaker 2: So here's a bit about how that shows up. For psyriasis. Specifically, 392 00:22:45,119 --> 00:22:48,840 Speaker 2: the presentation of the disease on darker skin tones looks 393 00:22:48,840 --> 00:22:52,000 Speaker 2: different than what is shown in most textbooks. The plaques 394 00:22:52,040 --> 00:22:55,920 Speaker 2: on darker skin can appear violet, brown, or gray rather 395 00:22:55,960 --> 00:22:59,840 Speaker 2: than red. The symptoms may look different, and for generations 396 00:22:59,880 --> 00:23:02,920 Speaker 2: of physicians that were trained on a library of images 397 00:23:03,320 --> 00:23:08,120 Speaker 2: that depicted almost exclusively light or pale skin, that difference 398 00:23:08,160 --> 00:23:13,520 Speaker 2: in presentation has contributed to diagnostic delays, to misdiagnosis, and 399 00:23:13,720 --> 00:23:18,840 Speaker 2: to undertreated disease. Studies suggest that black patients may receive 400 00:23:18,960 --> 00:23:23,880 Speaker 2: less information about biologics and feel less comfortable with self injection, 401 00:23:24,560 --> 00:23:27,880 Speaker 2: And some of it may be implicit bias operating at 402 00:23:27,880 --> 00:23:31,080 Speaker 2: the level of the clinical encounter itself. And this is 403 00:23:31,119 --> 00:23:35,040 Speaker 2: something that not only affects doctors by any means. Obviously, 404 00:23:35,160 --> 00:23:37,240 Speaker 2: this is a point of discussion in a lot of 405 00:23:37,240 --> 00:23:40,480 Speaker 2: different professions, but the data does seem to suggest that 406 00:23:40,560 --> 00:23:43,159 Speaker 2: some of this might be in play in the clinical setting. 407 00:23:43,480 --> 00:23:45,840 Speaker 2: It is hard to pinpoint, and that's what makes this 408 00:23:45,960 --> 00:23:49,719 Speaker 2: problem so pernicious, Doctor Anna. In your practice and on 409 00:23:49,760 --> 00:23:53,280 Speaker 2: your platform, I know you encounter patients every single day 410 00:23:53,640 --> 00:23:56,840 Speaker 2: that are dealing with the downstream consequences of a medical 411 00:23:56,880 --> 00:23:59,399 Speaker 2: system that just was not built with them in mind. 412 00:24:00,000 --> 00:24:03,360 Speaker 2: What are those conversations like when you're actually maybe explaining 413 00:24:03,400 --> 00:24:06,520 Speaker 2: to patients why they have not gotten the care that 414 00:24:06,760 --> 00:24:07,800 Speaker 2: they might otherwise. 415 00:24:08,640 --> 00:24:11,399 Speaker 3: I do believe people try their best when they see you. 416 00:24:11,440 --> 00:24:14,760 Speaker 3: But we all have different backgrounds. Someone may not have 417 00:24:14,840 --> 00:24:17,760 Speaker 3: traveled as much or interacted with many people of a 418 00:24:17,800 --> 00:24:21,080 Speaker 3: certain culture you know, and may just not know about 419 00:24:21,080 --> 00:24:24,399 Speaker 3: certain cultural customs. And when you pick a doctor, it's 420 00:24:24,560 --> 00:24:28,000 Speaker 3: you have to pick someone not just educational, but maybe 421 00:24:28,000 --> 00:24:30,480 Speaker 3: this person what through experiences that I can relate to 422 00:24:30,960 --> 00:24:34,119 Speaker 3: and trying to relate to the patient. I appreciate it 423 00:24:34,119 --> 00:24:37,080 Speaker 3: when patients tell you on the spot why they had 424 00:24:37,080 --> 00:24:39,639 Speaker 3: a bad experience. Sometimes a patient will come to me 425 00:24:39,680 --> 00:24:41,440 Speaker 3: and say, hey, you know, I just had this horrible 426 00:24:41,480 --> 00:24:45,000 Speaker 3: experience there, and well, why what did they do that 427 00:24:45,119 --> 00:24:48,359 Speaker 3: made you have that bad experience? You know, not just 428 00:24:48,480 --> 00:24:51,720 Speaker 3: to learn how that patient is or what bothers them 429 00:24:51,760 --> 00:24:54,679 Speaker 3: or what doesn't bother them, but also things not to 430 00:24:54,720 --> 00:24:57,679 Speaker 3: do in my practice that I hear repeated. It just 431 00:24:57,720 --> 00:25:01,119 Speaker 3: helps me grow and learn. So I think going with 432 00:25:01,200 --> 00:25:04,360 Speaker 3: an open mind, you know, is helpful when you're being 433 00:25:04,400 --> 00:25:06,480 Speaker 3: seen by a new doctor, but also when you're seeing 434 00:25:06,480 --> 00:25:10,040 Speaker 3: a new patient, asking open ended questions and then pointing 435 00:25:10,080 --> 00:25:13,160 Speaker 3: out those things that maybe bothered you from prior experiences 436 00:25:13,280 --> 00:25:16,120 Speaker 3: pretty much from the beginning, or or trying to mend 437 00:25:16,119 --> 00:25:17,240 Speaker 3: them before they happen. 438 00:25:18,000 --> 00:25:21,360 Speaker 2: You have accidentally perfectly teed up this next section because 439 00:25:21,720 --> 00:25:24,640 Speaker 2: we are going to talk a little bit about self advocacy, 440 00:25:25,080 --> 00:25:27,240 Speaker 2: what we can do to make sure that we're getting 441 00:25:27,240 --> 00:25:30,840 Speaker 2: the most out of our appointments with clinicians. Like doctor Anna, 442 00:25:31,000 --> 00:25:35,479 Speaker 2: self advocacy is incredibly powerful. A twenty twenty two study 443 00:25:35,480 --> 00:25:38,120 Speaker 2: that was published in the Proceedings of the National Academy 444 00:25:38,160 --> 00:25:41,760 Speaker 2: of Sciences looked at what happens when patients were trained 445 00:25:41,800 --> 00:25:45,600 Speaker 2: to be what the researchers called activated, meaning that they 446 00:25:45,640 --> 00:25:48,639 Speaker 2: came to appointments with a list of questions, they asked 447 00:25:48,640 --> 00:25:52,240 Speaker 2: for clarification when they didn't understand something, and they advocated 448 00:25:52,280 --> 00:25:55,880 Speaker 2: clearly for their own needs. The doctors in this study 449 00:25:56,280 --> 00:25:59,439 Speaker 2: didn't actually know that they were being observed, and what 450 00:25:59,480 --> 00:26:03,360 Speaker 2: the research Jure's found was this, when those patients were activated, 451 00:26:03,720 --> 00:26:07,119 Speaker 2: the effects of physician implicit bias on the quality of 452 00:26:07,160 --> 00:26:12,480 Speaker 2: the interaction essentially disappeared. Their bias didn't just suddenly go away, 453 00:26:12,600 --> 00:26:15,800 Speaker 2: but its ability to shape that encounter did, which is 454 00:26:15,880 --> 00:26:19,879 Speaker 2: so fascinating. Doctor Anna, as someone who is a human. 455 00:26:20,040 --> 00:26:22,919 Speaker 2: So thus you have been a patient who has navigated 456 00:26:22,920 --> 00:26:25,679 Speaker 2: the medical system and a physician who works from the 457 00:26:25,720 --> 00:26:28,400 Speaker 2: inside of it. What does that finding mean to you. 458 00:26:29,240 --> 00:26:31,920 Speaker 4: Every patient should be a self advocate as much as 459 00:26:31,920 --> 00:26:34,520 Speaker 4: you can, because, especially if you have a chronic condition, 460 00:26:35,119 --> 00:26:37,439 Speaker 4: your outcome will depend a lot on the management that 461 00:26:37,480 --> 00:26:40,840 Speaker 4: you choose long term. But also communicating you have to 462 00:26:40,880 --> 00:26:44,359 Speaker 4: ask questions, express concerns and just be honest, Like we 463 00:26:44,480 --> 00:26:46,480 Speaker 4: talked about it, what works and what doesn't work. 464 00:26:46,520 --> 00:26:48,520 Speaker 5: A lot of times if you're not, you actually won't 465 00:26:48,520 --> 00:26:50,800 Speaker 5: get better. As great of a doctor as you have, 466 00:26:50,920 --> 00:26:52,639 Speaker 5: you might have in front of you. You have to 467 00:26:52,680 --> 00:26:55,760 Speaker 5: speak up because that will directly influence your outcome. And 468 00:26:55,800 --> 00:27:00,240 Speaker 5: then think of the doctor patient relationship. Ideally, it's a team. 469 00:27:00,640 --> 00:27:03,920 Speaker 3: Not a hierarchy where you know, doctor's here and patients 470 00:27:03,960 --> 00:27:06,560 Speaker 3: down here. Know you have to be on the same 471 00:27:06,640 --> 00:27:08,800 Speaker 3: level and it's about teamwork. 472 00:27:09,600 --> 00:27:13,119 Speaker 2: You mentioned the importance too, and reiterated the importance of 473 00:27:13,160 --> 00:27:16,600 Speaker 2: self advocacy. But what's important too is that the researchers 474 00:27:16,600 --> 00:27:20,160 Speaker 2: were very careful in this to note something very important, 475 00:27:20,160 --> 00:27:24,359 Speaker 2: which is it the fact that patient activation can interrupt 476 00:27:24,600 --> 00:27:28,359 Speaker 2: bias doesn't mean that patients should bear the burden of 477 00:27:28,400 --> 00:27:32,879 Speaker 2: fixing a system level problem. And I think your note 478 00:27:33,000 --> 00:27:35,159 Speaker 2: about staying on the same level and not having a 479 00:27:35,240 --> 00:27:39,160 Speaker 2: hierarchy about it, yeah, is probably a big a big 480 00:27:39,200 --> 00:27:41,159 Speaker 2: portion of it of what the physician can do on 481 00:27:41,200 --> 00:27:44,719 Speaker 2: their end to help fix that system wide problem. What 482 00:27:44,760 --> 00:27:47,359 Speaker 2: this does, obviously mean all of this information is that 483 00:27:47,480 --> 00:27:50,399 Speaker 2: knowledge is power. As a patient, knowing your rights in 484 00:27:50,440 --> 00:27:53,760 Speaker 2: the room, knowing the questions worth asking, knowing that you 485 00:27:53,800 --> 00:27:57,520 Speaker 2: are entitled to a full explanation, a real conversation, and, 486 00:27:57,640 --> 00:28:00,840 Speaker 2: as doctor Anna just pointed out, a genuine partnership. Those 487 00:28:00,840 --> 00:28:05,120 Speaker 2: things really matter, and organizations like the National Psoriasis Foundation 488 00:28:05,280 --> 00:28:09,439 Speaker 2: have built free resources specifically to help patients prepare for 489 00:28:09,600 --> 00:28:13,960 Speaker 2: exactly that kind of conversation. They're patient navigators. There are 490 00:28:14,040 --> 00:28:19,399 Speaker 2: appointment guides provider directories that flag physicians with specific sooriatic 491 00:28:19,440 --> 00:28:24,040 Speaker 2: disease experience. The story of how medicine built its knowledge 492 00:28:24,040 --> 00:28:27,600 Speaker 2: base is not a finished story. Of course, that knowledge 493 00:28:27,640 --> 00:28:31,280 Speaker 2: base is getting bigger every day. But what has changed 494 00:28:31,440 --> 00:28:34,400 Speaker 2: is that now the gaps are visible, they have been 495 00:28:34,480 --> 00:28:39,120 Speaker 2: named and studied and increasingly built into how we design research. 496 00:28:39,520 --> 00:28:43,400 Speaker 2: And the people doing that work include dermatologists like doctor Anna, 497 00:28:43,480 --> 00:28:47,160 Speaker 2: who use every tool at their disposal, their platform, their practice, 498 00:28:47,520 --> 00:28:50,120 Speaker 2: their own patient history to reach the people that the 499 00:28:50,200 --> 00:28:53,520 Speaker 2: system has been missing. Doctor Anna, I think what today 500 00:28:53,520 --> 00:28:56,240 Speaker 2: has been about is the more you understand, the better 501 00:28:56,320 --> 00:28:58,480 Speaker 2: equipped you are to be the partner in your own 502 00:28:58,560 --> 00:29:01,360 Speaker 2: care that you deserve to be. We of course want 503 00:29:01,360 --> 00:29:03,760 Speaker 2: partnership in the exam room. I'm so glad you brought 504 00:29:03,760 --> 00:29:04,120 Speaker 2: that up. 505 00:29:04,480 --> 00:29:08,640 Speaker 3: Yeah, and also just something to tell everyone because we 506 00:29:08,680 --> 00:29:12,040 Speaker 3: all have good days and bad days, and patients, it's 507 00:29:12,080 --> 00:29:14,720 Speaker 3: normal and natural to forget to ask a very important 508 00:29:14,800 --> 00:29:17,800 Speaker 3: question in a visit. I think when you're looking at, 509 00:29:17,880 --> 00:29:20,760 Speaker 3: you know, the doctor patient relationship as a team, you 510 00:29:20,880 --> 00:29:24,240 Speaker 3: hopefully feel comfortable enough and it's hopefully easy enough to 511 00:29:24,360 --> 00:29:28,000 Speaker 3: just schedule follow up and discuss any pending questions that 512 00:29:28,040 --> 00:29:30,680 Speaker 3: you have in anything you might have forgotten or need 513 00:29:30,720 --> 00:29:35,440 Speaker 3: clarification on. Hopefully with teleodermatology that if you need to 514 00:29:35,480 --> 00:29:38,120 Speaker 3: go into the office for procedure, that's one thing, but 515 00:29:38,200 --> 00:29:40,959 Speaker 3: if you just need clarification, you could just do it 516 00:29:41,000 --> 00:29:42,880 Speaker 3: from the comfort of your home, and you should be 517 00:29:42,960 --> 00:29:45,040 Speaker 3: able to do it like that perfect. 518 00:29:45,520 --> 00:29:49,040 Speaker 2: I have two more questions for you today. We ask 519 00:29:49,160 --> 00:29:51,800 Speaker 2: these at the end of every episode of our Guests. 520 00:29:52,120 --> 00:29:55,560 Speaker 2: The first is what suggestions do you have for people 521 00:29:55,640 --> 00:29:59,240 Speaker 2: who maybe don't have psoriasis themselves, but they love someone 522 00:29:59,240 --> 00:30:01,719 Speaker 2: who does. I have a feeling you're going to suggest 523 00:30:01,760 --> 00:30:04,200 Speaker 2: that they be the person that goes to appointments with them. 524 00:30:05,120 --> 00:30:08,239 Speaker 3: I yeah, I do, and I think it's important you 525 00:30:08,240 --> 00:30:11,800 Speaker 3: know that if you care about someone, you bring up 526 00:30:12,000 --> 00:30:14,800 Speaker 3: whether it's a medical issue, that's bothering them or how 527 00:30:14,840 --> 00:30:17,840 Speaker 3: they can get better. I know that you know we 528 00:30:17,920 --> 00:30:19,760 Speaker 3: all want to do that for our families because we 529 00:30:19,800 --> 00:30:22,840 Speaker 3: want the best for them and friends and close friends. 530 00:30:23,440 --> 00:30:26,640 Speaker 3: So I think, yeah, just looking up resources trying to 531 00:30:26,640 --> 00:30:28,479 Speaker 3: go with them to appointment, you could even go with 532 00:30:28,520 --> 00:30:31,080 Speaker 3: them to a virtual appointment and not even have to 533 00:30:31,120 --> 00:30:34,040 Speaker 3: move if you feel like you know their health could 534 00:30:34,040 --> 00:30:36,120 Speaker 3: be better, they just may not know what to do. 535 00:30:36,880 --> 00:30:40,040 Speaker 2: And then, last, but not least, if you could send 536 00:30:40,120 --> 00:30:42,840 Speaker 2: one message to any of our listeners who might be 537 00:30:42,920 --> 00:30:45,560 Speaker 2: grappling with their own diagnosis, what would that be? 538 00:30:46,120 --> 00:30:49,479 Speaker 3: I would say to not give up. Sometimes it takes 539 00:30:49,760 --> 00:30:52,200 Speaker 3: more than one person that you might have to see 540 00:30:52,320 --> 00:30:56,360 Speaker 3: to tackle a problem. And come to an appointment with 541 00:30:56,440 --> 00:31:00,000 Speaker 3: an open mind, a plan, and a voice, ask questions, 542 00:31:00,240 --> 00:31:03,280 Speaker 3: be honest, and don't be afraid to be a self advocate. 543 00:31:03,440 --> 00:31:07,280 Speaker 3: And the best dermatology and medical care comes when patients 544 00:31:07,320 --> 00:31:09,640 Speaker 3: are informed, engaged and empowered. 545 00:31:10,080 --> 00:31:12,040 Speaker 2: I love it, doctor Anna, Thank you so much for 546 00:31:12,080 --> 00:31:14,600 Speaker 2: spending this time with us. Of course, thank you so 547 00:31:14,680 --> 00:31:21,320 Speaker 2: much of my pleasure. Our skim is hosted by myself, 548 00:31:21,400 --> 00:31:25,240 Speaker 2: Holly Frye and executive produced and engineered by Ryan Martz. 549 00:31:25,680 --> 00:31:29,240 Speaker 2: Our executive producer and writer is Meredith Barnes. If you 550 00:31:29,360 --> 00:31:32,000 Speaker 2: enjoy the show, share it with your friends. You can 551 00:31:32,040 --> 00:31:35,840 Speaker 2: also listen and follow on the iHeartRadio app, Apple Podcasts, 552 00:31:35,920 --> 00:31:37,680 Speaker 2: or wherever you get your podcasts.