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Cleaning your hands: what’s the skinnection? Can cleaning your hands make you a better dermatopathologist?


Dr. Hafeez Diwan

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Almost every dermatopathologist has had this feeling. You go to a meeting, for example, and hear a talk about the diagnoses which were missed and the often disastrous consequences that ensued – both for the patient and for the dermatopathologist, legally, financially, and morally. Nobody wants to miss important diagnoses. This is never more so than when it comes to melanocytic lesions. I usually return from dermatopathology meetings with that Sixth Sense-esque feeling of I-see-melanomas (the boy in the famous movie, The Sixth Sense, you will recall, claimed that he could see dead people). Or, following the last ASDP meeting, after seeing how many zoster cases could be missed, I have gone on a near I-want-to-find-zoster rampage. It is human nature, and being human, I have as much chance of escaping my nature as the scorpion that stung the frog that was ferrying it across the water. When the frog asked the scorpion why it had such a remarkably stupid thing (since both of them would now drown), the scorpion answered, “It is my nature, and I can’t change it.” To misquote Hermes, As below (with scorpions), so above (above as in higher up the evolutionary ladder, with dermatopathologists like me).

As I am sure you will agree, what is happening is that our exposure to something (in this example the meeting) influences our behavior, or [i]primes[/i] us. Priming is a well known and well studied phenomenon. Consider the following study, by Bargh et al. (Bargh JA, Chen M, Burrows L. Automaticity of social behavior: direct effects of trait construct and stereotype activation on action. Journal of Personality and Social Psychology 1996: 71(2):230-244):

Bargh et al. primed the subjects to be either rude, polite or to be in a neutral state of mind. They did this by giving subjects sentences to unscramble. Cleverly, the sentences to the rude group contained words like [i]bother[/i], [i]rude[/i], [i]interrupt[/i], [i]annoyingly[/i] and [i]obnoxious[/i]. Those of the polite group had words like [i]polite[/i], [i]yield[/i] and [i]courteous[/i]. The neutral group had words such as [i]send[/i] and [i]watches[/i]. Upon completion of the task, the subject was supposed to walk up to the experimenter. When he did so, the experimenter would signal to a confederate who would pretend to be a subject and ask the experimenter questions regarding the study and the instructions, and to quote the paper, exhibit the behavior of “just not getting it.” This would go on for a maximum of 10 minutes. The length of time it took for the subject (the true subject) to interrupt the experimenter-confederate conversation was recorded. Bargh et al. found that the rude-primed subjects were more likely to interrupt than the polite-primed ones. In other words, a prior exposure had influenced and primed a later action.

This has great implications in the practice of dermatopathology. Our being hyper-alert to missing important diagnoses can make us more susceptible to the lure of certain diagnoses, diagnoses that may not be entirely accurate. Consider the oft-observed contention that the number of melanomas being diagnosed has increased in the past few decades. It is entirely possible that we are being pummeled by solar energy far more aggressively than we were, say, thirty years ago, but several dermatopathologists are of the view that maybe, just maybe, we may be overcalling melanomas. How often does one see a case and wonder, “I would never have called such-and-such case a melanoma” or the opposite, “I would have probably called this a melanoma.” Of course, subjective variations may account for some of this, but I am of the view that we are scared to miss melanoma to varying degrees, and some of us are more scared than others, and are therefore more prone to mistake ropes for snakes. A diagnosis of melanoma, overcalled, is less likely to get you sued (but you can still get sued for an overcall, though not as often as for undercalling). I have heard somebody mention a mantra of Dr. McKee’s: reportedly, he would often say in the morning, several times, “I will not miss a nevoid melanoma.” (I have not heard this directly from Dr. McKee, and so I can’t vouch for the veracity of this anecdote. But the thought is admirable. I have mentally started reciting a similar mantra when I sign-out.) From the patient’s perspective, once a patient gets labeled with a melanoma, correctly or incorrectly, the consequences for his/her healthcare and insurance are tremendous.

So what is one to do? Consider the following:

In an intriguing study, published in Science in 2006 (see Zhong C, Liljenquist K. Washing away your sins: threatened morality and physical cleansing. Science 2006:313(5792);1451-1452), the investigators made subjects recall an unethical incident from their lives, a time when they had behaved badly. Then, subjects either cleaned their hands with an antiseptic wipe or they didn’t. Then they did a survey about their emotional state. Finally, they asked the participants if they would be willing to volunteer in a study, for free, to help out a “desperate graduate student.” Interestingly, those subjects who had cleaned their hands were less likely (41%) as the non-washers (74%) to agree to help out and do something for free. Their conclusion? Washing hands may have had the effect, unconsciously in their minds, of washing away their sins (in fact, the emotional survey of the hand-washers showed fewer moral emotions such as guilt, regret, shame, embarrassment and anger). Many religions and cultures attach importance to washing (for example, a ritual washing before praying), and this religio-cultural “understanding” could have been parlayed, likely unconsciously, in a decreased willingness to help out (the washing had removed some of their guilt, making them less susceptible to pleas for help. I don’t know about you, but I become far more giving and forgiving when I feel guilty about some transgression). (Shakespeare was unaware of this study, having died 390 years prior to its publication. But recall that in his play, Lady Macbeth, after being involved in several murders, complained that, “All the perfumes of Arabia will not sweeten this little hand.” Shakespeare obviously knew something about the hand-guilt connection.)

Now, obviously it would be naïve to suggest that we can become better dermatopathologists simply by washing our hands. But it is a simple enough act to do (providing you aren’t obsessive about it). There are times we are wondering if we are missing something important, or wondering if we have missed something important in the past, or wondering what important stuff we’ll miss tomorrow. I admit this is not quite the same as having committed an unethical deed in the past, but I will submit that what we feel at such times is a moral emotion, whether it be guilt or regret or shame or embarrassment (at not being confident enough to settle on a diagnosis, or not pleasing our clinicians with a concrete diagnosis, or not providing optimal service to our patients, or causing our patients harm by missing something critical). Such being the case, as members of the human race and subject to the same weakness as other humans – might we not remind ourselves of priming, and might we not take a breather, get up, walk to the basin and run some water on our hands – with soap being optional (and too much soap, too often, might not be good for our skin)? A break in sign-out never hurt anybody, and with the guilt reduced by hand washing (after all, a publication in Science, no less, says so!), might we then not be in a slightly more impartial frame of mind, and slightly better at what we are about to do? I know it sounds kooky and outrageous, but to quote Hamlet, there are more things in heaven and earth than are dreamt of by our (rational) philosophy.

If I were criticizing my blog I would say that what I have suggested seems a bit of a stretch, but I would also say that we really don’t know. Maybe we need a study of dermatopathologists who wash their hands, say five times during a defined period of sign-out and then see the kinds of diagnoses they made, compared to those who don’t wash their hands in this manner. In fact, as soon as I finish writing this, I am going to write up a proposal to study this. Any volunteers?
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Dr. Phillip McKee

Posted

It is nice to see so much philosophy in your blog. I have similar views although my approach is somewhat different. My first mantra in the day is to look at myself in the mirror to make sure I know who I am (good practice for the 60's and older!) Yes, I have often said that before each signout I have a matra of "I mustn't forget nevoid melanoma, desmoplastic melanoma in scar tissue" and I also throw in cellular neurothekeoma as I always forget about it. I very much agree that there is considerable risk of over-diagnosing melanoma, particularly in situ lesions. Indeed I have received a consultation asking is this a dysplastic nevus with severe atypia or in situ melanoma on so many occasions. Unless it is obvious, I generally reply that it doesn't matter very much since the treatment is the same. This is ducking the issue but sometimes it is impossible for anyone to know. I have always been a very pragmatic pathologist (probably comes from my very Victorian childhood) and also how I was trained. I don't have any gray areas. Either it is an invasive melanoma or it is not. I constantly preach that if you aren't sure, set it aside until the next day and after a good nights sleep, the issue is almost invariably solved. I think that everyone should remember the consequences of their actions especially for the patient and use any means possible (including sleep) to ensure that they are neither overdiagnosing nor underdiagnosing. To end up diagnosing the lesion as atypical (again on my hobby horse) just because you can't make up your mind is lamentable. Your colleagues and consultations are there to help you.
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Dr. Mona Abdel-Halim

Posted

I am learning everytime from those lovely philosophical blogs of you Dr Diwan and from the valuable comments of Dr McKee,,,,,
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Mark A. Hurt MD

Posted

Thank you all for your comments on this matter. I think, as a rule, there is little hurry to make a mistake. When anyone shows me a case, I always ask, "Why are your showing me this if you are certain?" Invariably, the answer is "I'm not certain." Instead of hand washing, I think it is extremely important for one to recognize that when he or she hesitates in developing a diagnosis, it has real meaning, and it should not be forced. There is no disgrace in not knowing; there [u][i]is[/i][/u] in forcing the issue beyond one's knowledge.
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