People hold many beliefs simply because they were taught to believe them. Other beliefs are supported by experience, and sometimes by a lot of experience. But many of these beliefs can be plain wrong.
I’ve been wrong in my professional life numerous times. I have one area of clinical expertise: psoriasis. I study psoriasis and I manage psoriasis patients. I have a lot of experience with psoriasis. But there have been times when my beliefs about psoriasis have been completely and irrevocably wrong.
Question Beliefs
Take tachyphylaxis, for example. I was taught that over time topical corticosteroids often stop working. Tachyphylaxis was defined for me as “the more you use the topical steroid, the less it works.” The mentors that taught me about tachyphylaxis were the giants of dermatology and I accepted their vision of this condition and, for years, practiced under that belief.
But now, it seems pretty clear to me that the statement: “the more you use the topical steroid, the less it works,” is not a correct description of the situation.
Instead, I find that the less you use a topical steroid, the less it works. The problem is not with corticosteroid receptors. The problem is with topical corticosteroids not being applied to the skin. Evidence to support this is very strong; no clinical trial has ever demonstrated tachyphylaxis to topical corticosteroids in the treatment of psoriasis or any other inflammatory dermatoses. Instead, compliance studies clearly demonstrated the reduction in patients’ use of topical medications over time.
Simply accepting a belief that was taught to me and ignoring the research would mean possibly denying patients a treatment that works.
Listen to Patients
The use of topical ointments is another example of a belief about psoriasis that was wrong.
My mentors taught me that when treating psoriasis with topicals, I should use ointment vehicles. I practiced that way for more than a decade and, in turn, taught that same lesson to my dermatology residents. But our patients’ disdain for ointments screams out at us.
Poor compliance to ointments should, by this point, be both obvious and expected.
How did we ever come to believe that we should try to force ointments on patients with psoriasis? It makes no sense to me. But that is what we believed and some of us still believe that. Maybe if a patient asks us for an ointment, we should use it. But otherwise, we ought to consider offering our patients a less messy preparation that they would be more likely to use.
Stay Open to New Treatments
Today, we know that TNF inhibitors are a huge advance in the treatment of psoriasis. But a few years ago, that knowledge wasn’t there. I remember receiving a bunch of calls from investment bankers asking if TNF inhibitors would be good drugs for psoriasis. I told them “no”, thinking the inhibitors didn’t work. I had seen numerous patients with psoriasis, some of them with psoriatic arthritis treated by a rheumatologist with a TNF inhibitor. None of these patients were clear of their disease. None were even substantially improved.
Of course, now I know that TNF inhibitors are very effective. I also know that my understanding of these treatments led me to my false assumption; the only patients that were referred to me by rheumatologists were those whose psoriasis didn’t improve with a TNF inhibitor. The ones whose psoriasis had improved had no need for a referral; their treatment was a success.
The longer I’m in practice, the more I see the importance of questioning my beliefs. I’m more humble in my professional beliefs than I used to be.
People hold many beliefs simply because they were taught to believe them. Other beliefs are supported by experience, and sometimes by a lot of experience. But many of these beliefs can be plain wrong.
I’ve been wrong in my professional life numerous times. I have one area of clinical expertise: psoriasis. I study psoriasis and I manage psoriasis patients. I have a lot of experience with psoriasis. But there have been times when my beliefs about psoriasis have been completely and irrevocably wrong.
Question Beliefs
Take tachyphylaxis, for example. I was taught that over time topical corticosteroids often stop working. Tachyphylaxis was defined for me as “the more you use the topical steroid, the less it works.” The mentors that taught me about tachyphylaxis were the giants of dermatology and I accepted their vision of this condition and, for years, practiced under that belief.
But now, it seems pretty clear to me that the statement: “the more you use the topical steroid, the less it works,” is not a correct description of the situation.
Instead, I find that the less you use a topical steroid, the less it works. The problem is not with corticosteroid receptors. The problem is with topical corticosteroids not being applied to the skin. Evidence to support this is very strong; no clinical trial has ever demonstrated tachyphylaxis to topical corticosteroids in the treatment of psoriasis or any other inflammatory dermatoses. Instead, compliance studies clearly demonstrated the reduction in patients’ use of topical medications over time.
Simply accepting a belief that was taught to me and ignoring the research would mean possibly denying patients a treatment that works.
Listen to Patients
The use of topical ointments is another example of a belief about psoriasis that was wrong.
My mentors taught me that when treating psoriasis with topicals, I should use ointment vehicles. I practiced that way for more than a decade and, in turn, taught that same lesson to my dermatology residents. But our patients’ disdain for ointments screams out at us.
Poor compliance to ointments should, by this point, be both obvious and expected.
How did we ever come to believe that we should try to force ointments on patients with psoriasis? It makes no sense to me. But that is what we believed and some of us still believe that. Maybe if a patient asks us for an ointment, we should use it. But otherwise, we ought to consider offering our patients a less messy preparation that they would be more likely to use.
Stay Open to New Treatments
Today, we know that TNF inhibitors are a huge advance in the treatment of psoriasis. But a few years ago, that knowledge wasn’t there. I remember receiving a bunch of calls from investment bankers asking if TNF inhibitors would be good drugs for psoriasis. I told them “no”, thinking the inhibitors didn’t work. I had seen numerous patients with psoriasis, some of them with psoriatic arthritis treated by a rheumatologist with a TNF inhibitor. None of these patients were clear of their disease. None were even substantially improved.
Of course, now I know that TNF inhibitors are very effective. I also know that my understanding of these treatments led me to my false assumption; the only patients that were referred to me by rheumatologists were those whose psoriasis didn’t improve with a TNF inhibitor. The ones whose psoriasis had improved had no need for a referral; their treatment was a success.
The longer I’m in practice, the more I see the importance of questioning my beliefs. I’m more humble in my professional beliefs than I used to be.
People hold many beliefs simply because they were taught to believe them. Other beliefs are supported by experience, and sometimes by a lot of experience. But many of these beliefs can be plain wrong.
I’ve been wrong in my professional life numerous times. I have one area of clinical expertise: psoriasis. I study psoriasis and I manage psoriasis patients. I have a lot of experience with psoriasis. But there have been times when my beliefs about psoriasis have been completely and irrevocably wrong.
Question Beliefs
Take tachyphylaxis, for example. I was taught that over time topical corticosteroids often stop working. Tachyphylaxis was defined for me as “the more you use the topical steroid, the less it works.” The mentors that taught me about tachyphylaxis were the giants of dermatology and I accepted their vision of this condition and, for years, practiced under that belief.
But now, it seems pretty clear to me that the statement: “the more you use the topical steroid, the less it works,” is not a correct description of the situation.
Instead, I find that the less you use a topical steroid, the less it works. The problem is not with corticosteroid receptors. The problem is with topical corticosteroids not being applied to the skin. Evidence to support this is very strong; no clinical trial has ever demonstrated tachyphylaxis to topical corticosteroids in the treatment of psoriasis or any other inflammatory dermatoses. Instead, compliance studies clearly demonstrated the reduction in patients’ use of topical medications over time.
Simply accepting a belief that was taught to me and ignoring the research would mean possibly denying patients a treatment that works.
Listen to Patients
The use of topical ointments is another example of a belief about psoriasis that was wrong.
My mentors taught me that when treating psoriasis with topicals, I should use ointment vehicles. I practiced that way for more than a decade and, in turn, taught that same lesson to my dermatology residents. But our patients’ disdain for ointments screams out at us.
Poor compliance to ointments should, by this point, be both obvious and expected.
How did we ever come to believe that we should try to force ointments on patients with psoriasis? It makes no sense to me. But that is what we believed and some of us still believe that. Maybe if a patient asks us for an ointment, we should use it. But otherwise, we ought to consider offering our patients a less messy preparation that they would be more likely to use.
Stay Open to New Treatments
Today, we know that TNF inhibitors are a huge advance in the treatment of psoriasis. But a few years ago, that knowledge wasn’t there. I remember receiving a bunch of calls from investment bankers asking if TNF inhibitors would be good drugs for psoriasis. I told them “no”, thinking the inhibitors didn’t work. I had seen numerous patients with psoriasis, some of them with psoriatic arthritis treated by a rheumatologist with a TNF inhibitor. None of these patients were clear of their disease. None were even substantially improved.
Of course, now I know that TNF inhibitors are very effective. I also know that my understanding of these treatments led me to my false assumption; the only patients that were referred to me by rheumatologists were those whose psoriasis didn’t improve with a TNF inhibitor. The ones whose psoriasis had improved had no need for a referral; their treatment was a success.
The longer I’m in practice, the more I see the importance of questioning my beliefs. I’m more humble in my professional beliefs than I used to be.
