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The 'Whirling' Dermatopathologist: Can NOT looking hard at a case make you a more confident and competent dermatopathologist?


Dr. Hafeez Diwan

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Imagine you have been given a task as follows: Rearrange the following words to form another word, but do not attempt to unscramble a word further down the list until you have successfully solved the preceding word. Here are the words: “whirl,” “slapstick,” and “cinerama.” Unless you have a brain disorder that makes you incredibly, even supernaturally smart, I am willing to bet that you will find it difficult, if not impossible to unscramble the words “whirl” and “slapstick” to make another word that uses all the letters. (I used an online unscrambling tool and was unable to find a single word that uses all the letters of “whirl” and “slapstick” to make a new word. It is possible to make “whir” out of “whirl,” and “plastic” or “lap” or “cat” out of “slapstick,” but I don’t know of another word that uses the 5 letters of whirl to make a different 5-letter word (or uses all nine letters of slapstick to make a different 9-letter word. I am sure some would love to prove me wrong, so go ahead, but remember the unscrambled words should be in English, not Hungarian or Swahili or some other foreign language).

Dr. Charisse Nixon gave the three words above to half of a group of students with the same instructions, but to the other half of this group she gave the words “bat,” “lemon,” and “cinerama.” (The students had no idea that half of them had received easy words.) After giving the group a chance to rearrange the first word (either the impossible-to-unscramble “whirl” or easy as pie “bat”), she asked those who had finished the first word to raise their hands. Predictably, half the group raised their hands. She then asked everyone to move on word number 2 (either “slapstick” or “lemon”). Lemon is easily rearranged into melon, and so again, when she asked for a show of hands, half the group raised their hands indicating they were done with the second word. She then asked the group to move to the third word, which was “cinerama” for both halves. The group that got the easy words 1 and 2 were easily able to rearrange “cinerama” into “American.” Interestingly, the group that got the impossible words 1 and 2 found it difficult to unscramble “cinerama.” We can ask: what’s going on?

It is tempting to conclude that receiving the difficult words 1 and 2 sapped the confidence of the students, making it seem that the problems were close to insurmountable. Seeing all the other hands going up must have felt even more ego-depleting (I can imagine them thinking: “Am I really that stupid? How can the others unscramble these impossible words?”) The end result of this brief episode of “learned helplessness” might have been to (mentally) throw up their hands in despair when they came to cinerama (here I am taking poetic license – I don’t know if any of the students did indeed engage in cerebral hand-throwing). I took the test myself (a description of this test is recorded in the excellent book “You are Not so Smart” by David McRaney) and suffered the indignity of not being able to unscramble “cinerama.”

The connection, or “skinnection,” to the practice of Dermatopathology is obvious. How often are we forced to put a case aside because it is too difficult? I think some would agree that our bout with a tough case can leave its traces on our bruised psyches. If we get a string of difficult cases, like say, three “melanoma or not” cases from three 21-year-olds in succession (statistically unlikely to occur, but this is a hypothetical example), we might start looking into the oculars of a microscope like the proverbial deer caught in the headlights. Even a simple (or moderately difficult) case that followed might then seem incredibly challenging. We might start thinking fatalistically, “this is a bad day,” or, “oh no, every case is a pain today.” This is easily verifiable as incorrect: I have often gone back to some of the easier cases (that seemed difficult when they came after really tough cases), and seen them to be not as demanding as I had initially supposed. My conclusion: like Dr. Nixon’s students, I had been “trained” by the tough case(s) that preceded the easier ones to see myself as the victim of cruel circumstance or of a bad alignment of the stars.

And, here is my solution, one that I apply to my own sign-out sessions. If after the first look a case is not obvious to me, instead of struggling or battling with it, trying to make it yield its secrets, I calmly put it aside – for later. On bad days, I have had to put aside several such cases. Instead of losing my confidence, I wag my finger at Fate for sending such difficult cases my way, but move on rapidly, because I know that statistically speaking, the majority of cases will be fairly do-able and easier. In fact, I am able to delight in the easier cases that follow, regarding them as manna from heaven.

Now it is entirely possible that this is a problem that is unique to me, and that no other dermatopathologist has ever experienced this kind of situation. If so, I would be only too happy to hear from them. Or they could write their own blog (this is my blog, and so I am biased to project my own problems, and imply that there is some degree of universality to them). And I am sure they will also let me know that “whirl” can be easily unscrambled to form the word “_____”.
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Dr. Phillip McKee

Posted

Another wonderful blog. I too have always followed your practice but have also noted that often the difficult cases come nearer the end of the signout. Perhaps the residents and fellows have moved them to the end to speed up the signout. It never fails to amaze me how a difficult case in the late afternoon becomes an easy one the next morning. There is however also the real problem of looking too hard at a case and for far too long. I have always taught that first impressions are generally correct (it is like going over a multiple choice examination for a second time and changing all the corrcet answers to wrong ones). When one looks for example at a superficial dermal lymphocytic infiltrate, the longer one looks the more likely one is to start thinking that some of the lymphocytes are atypical and convert a benign lesion into a lymphoma.
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Mark A. Hurt MD

Posted

Very enjoyable blog! This is an interesting and daily problem, in my experience. As a rule, I find that when I encounter a case for which I can develop only a differential diagnosis but not a definitive diagnosis, that case requires one or more of 3 other decision points before it can be signed out:

1. Recut it
2. Stain it
3. Consult on it (internally, externally, or both)

In the meantime, the case goes into the subconscious for "processing." After the case comes back to me, it is astounding how many times I know what to do next, if nothing more to admit that I don't know the diagnosis.
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Dr. Mona Abdel-Halim

Posted

Very interesting, I now got used to keeping difficult cases aside for a while, sometimes I leave them for overnight processing and slow thinking, a second look after a while makes me see things clearer.
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Really very good blog!! And the way it was written, is like a story to a child. I think everyone does that in a difficult day, and might just be a self preservation instinct.
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