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The Israeli Parole Board and Dermatopathologists - What’s the Skinnection?


Dr. Hafeez Diwan

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The unifying theme behind this series of blogs is as follows: dermatopathologists are humans first and dermatopathologists second, and therefore, are as human as everybody else – including those judges that decide the fate of prisoners presenting to Israeli parole boards. I have created the somewhat cheesy term, “skinnection”, to emphasize that some of my blog postings will explore the connection between the mass of psychological data out there and pathologists who focus on the skin.

First, some background. Prisoners go before a parole board and make their appeals. The judge hears the appeal, listens to the advice of a criminologist and social worker and then finally decides whether to grant parole or deny it. This is where things get interesting. Danziger, Levav and Avnaim-Pesso evaluated 1,112 judicial decisions, gathered over 50 days in a ten month period (see Proceedings of the National Academy of Sciences USA, 2011 April 26;108(17):6889-6992). They found that favorable rulings went down from nearly 65% to close to zero within each decision session. That is to say, prisoners who went before the board immediately after breakfast, lunch or a snack were [i]far[/i] more likely to be granted parole than those who went before the mid-morning snack, before lunch, or later in the afternoon when lunch became a kind of distant memory. We could ask: what’s going on?

The common theme is food and the lack of it. Researchers have shown the importance of glucose in decision-making, and judges who decide the fate of prisoners make decisions all the time (14-35 per day in this study). In fact, in their article referenced above, Danziger et al. state that they ‘test the common caricature of realism that justice is “what the judge ate for breakfast.”’ In their abstract, they conclude that ‘judicial rulings can be swayed by extraneous variables that should have no bearing on legal decisions.’ Like food…Decisions literally use up glucose and when we are running on empty, our decisions can be affected.

The skinnection with what we do is obvious. Dermatopathologists are often the object of amusement by bemused observers who think we look at cases rather fast. But, as a poet once said, these observers are looking at the mountain, not the mine within it. Dermatopathologists look and decide, usually fast, but the speed is not the point (for the purposes of this discussion). The point is that we are making a decision every time we evaluate a microscopic slide. The same applies to other pathologists, but generally speaking, the number of cases seen by dermatopathologists usually exceeds that seen by general pathologists. People sometimes make the case that dermatopathologists see easy stuff (they’re all seb K’s and BCC’s, aren’t they…!), but this is obviously not the case. Troublesome cases are mixed in with the easy ones, and every dermatopathologist is terrified of the bland-appearing nevoid melanoma mixed in with a bunch of bland benign nevi. No slide comes with labels like: “I’m an easy case, so look at me fast,” or “I’m a sneaky one – be careful,” or, “I’m a terribly difficult case, so reach out for that candy bar.”

The point is we make a lot of decisions over the course of our work-day. Depending on the practice, a dermatopathologist could be reviewing a hundred, two hundred, or sometimes even more cases per day! That’s an enormous challenge to the brain and I wonder how our biology/physiology affects the quality of our diagnoses. It can’t be possible that somehow dermatopathologists have a pass on the biological limitations that bedevil non-dermatopathologist humans. In other words, we are probably being affected by it, and our diagnoses are also affected by it, possibly without even realizing it. I know from my own experience, that I become more “malignant” as the day wears on and I grow tired. I usually take a break, have some chocolate or tea, and then return to the task. At times, when it is possible, leaving a case for the next morning can have a miraculous therapeutic effect. A malignant lesion can magically turn benign after a good night’s sleep and a hearty breakfast.

So, here’s the skinnection: we dermatopathologists can serve our patients better by looking after ourselves, and nibbling on this and that judiciously. I am obviously not recommending we put on excess pounds, but just like the French women who don’t get fat, we dermatopathologists can keep a light snack handy.
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Dr. Phillip McKee

Posted

I like this blog as it has implications for all of us. On a facetious note, if I get stopped by the highway patrol for excessive speed, I should offer the officer a candy bar before showing him/her my license etc. It is certainly true that our workload id often huge and far too much for one sign-out. I usually set aside the difficult cases until the next day. Mind you that resulted in each "next day" getting progressively harder to get through if I had set aside too many cases to sleep (and feast) on. Still its not a perfect world and anything we can do to improve our diagnostic a
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Dr. Mona Abdel-Halim

Posted

Lovely blog and I do the same, stop for a snack, leave difficult cases aside for a while or for overnight processing...
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