As dermatologists we all have our individual styles of practice and favorite areas of dermatology on which we prefer to focus. But we all share one thing in common: We have a strong desire to improve our skills. Getting input from colleagues can help us achieve this goal. This column will highlight a wide range of pearls from practicing dermatologists — everything from a better way to perform a clinical procedure to a more effective method for communicating with patients to advice for improving an office function.
Tip 1: The Importance of Surgical Markings
An experienced physician or surgeon never underestimates the importance of pre-operative markings. These markings help delineate incision placement, anatomic landmarks, and areas of proposed treatment. Ideally, the markings should be made with the patient awake and alert in an upright and supine position. The patient should be made aware of the proposed markings and treatment areas prior to surgery by allowing him/her to inspect the surgical markings in front of a mirror prior to beginning a procedure. Documentation should also be made of this discussion by noting the following in the operative note:
Preoperative markings were made with the patient in front of a mirror. The patient was given adequate time to discuss the treatment plan, proposed risks, surgical markings, and areas of treatment while awake and alert prior to the initiation of the procedure. Surgical markers should also be durable enough to minimize the risk of accidental removal during surgery. In most cases, physicians employ commercially available sterile surgical markers or non-sterile permanent markers found in most office-supply stores. During smaller office-based cosmetic procedures, such as injectable fillers or other minimally invasive procedures, the use of permanent or semi-permanent markers may become prohibitive. The markers are usually not easily removable after the procedure and may further aggravate patients who must leave the clinic with telltale signs of having undergone a cosmetic procedure…blue and purple lines on the face. Our office has attained enormous success with preoperative markings using a clever and commercially available alternative to conventional surgical markers. We utilize a white-colored soft eye pencil (Rimmel) that is usually purchased at a beauty supply store. The make-up pencil allows easy identification of proposed treatment areas and is easily removed using tissue paper or gauze after treatment. In addition, the ingredients are rarely allergenic and are durable enough to withstand the duration of a smaller treatment. We have not had experience using the pencil with procedures requiring betadine preparation or longer operative duration. Of note, there are several types of eyebrow pencils marketed for commercial use. We have found that the soft eye pencils are far superior to the hard eye pencils in terms of overall durability as well as ease of removal. Raffy Karamanoukian, MD Hratch Karamanoukian, MD Santa Monica and Beverly Hills, CA
2: Apologizing for Running Late
Recently I went to a dental appointment, and when told she was running 30 to 40 minutes behind, I told the reception that I was going home and would rebook another time. That evening the dentist called me to personally apologize and explain that she values my time and that she was running late due to various unforeseen circumstances. Because of her phone call and kind gesture, I will stay in her practice. I will also personally call and apologize to any future patients who I am told left because I was running late. It is common courtesy (or perhaps not common enough), and it makes good business sense. Benjamin Barankin, MD, FRCPC Toronto, Canada
Tip 3: Cyclosporine Pearls
• Check baseline blood pressure and creatinine twice.
• Get fasting lipids.
• Initially examine patient, then check blood pressure every 2 weeks, then every month.
• Rule out active infection.
• Check serum potassium, magnesium and uric acid.
• Give patients magnesium supplementation.
• Let patient know they might experience acral tingling.
• Dose adequately and expect to give 4 mg/kg to 5 mg/kg.
• There are several versions of cyclosporine that include: 1.) Pill form — Neoral, Sandimmune, or Gengraf (which is similar to Neoral). These come in capsules of 25 mg, 100 mg or 250 mg; 2.) Liquid form — Neoral or SangCya, an oily liquid of 100 mg/ml; 3.) An intravenous form; and 4.) Topical form available as Restasis eye drops for dry eye. Note: Sandimmune and Neoral are not interchangeable at equal doses.
• Half-life is 5 to 18 hours, so it clears more quickly that any biologic. Specifically, half-life ranged from 6.3 hours in healthy volunteers to 20.4 hours in patients with severe liver disease.
• While many take it with apple or orange juice as this may improve taste, levels of SangCya (which has had marketing issues) can be changed by apple and orange juice.
• Giving it with grapefruit boosts its levels but the level increase can be hard to monitor.
• Risks of nephrotoxicity and hypertension increase with increasing duration of use.
• Do not expect to use it for more than 6 months or with phototherapy.
• It is not a medication of choice for obese patients or hypertensive patients.
• If you keep to monitoring guideline, creatinine will increase more than 30% only rarely.
• Transplant patients take 7 mg/kg to 15mg/kg — extrapolating their side effects to psoriatics is unclear.
• If a patient is NPO pre-op and post-op, give cyclosporine intravenously.
• When a patient is NPO pre-op and post-op, consult surgeon and nephrologist. Noah Scheinfeld, MD, JD New York, NY
Tip 4: Dermatologist, Watch Your Breath
Doctors may keep their clinic in order but may miss out on simple things like personal appearance and mouth odor. A well groomed appearance definitely soothes the sufferer, but what may be most annoying for patients is foul odor emanating from the doctor’s mouth. This is mainly due to overwork and not eating for long periods. Some foods like onions and garlic can emit a very strong odor, disagreeable to many patients. It also goes without saying that smell of tobacco or alcohol may have negative effects in dealing with a patient. Some of this can be avoided by being aware of the problem and taking steps to get over it. Khalid Al Aboud, MD King Faisal Hospital, Saudi Arabia
Tip 5: Humorous Answers to Patients’ Questions
1. After a minor procedure such as a shave biopsy, I’m sometimes asked, “Can I drive home after this?”
My response is, “Do you have a drivers license?”
Another variation is, “Can I shower after this?”
My response is, “Do you have indoor plumbing?” 2. Often, parents persistently ask me how I can “cure” their son’s or daughter’s warts.
My two responses are:
1. “If I knew how to ‘cure’ a wart, ie, cure a viral infection, I’d probably win the Nobel Prize.”
2. “Skin cancer is easy; warts are really tough!”
Herb Goodheart, MD Poughkeepsie, NY Dr. Barankin is a dermatologist based in Toronto, Canada. He is author-editor of five books in dermatology, and is widely published in the dermatology and humanities literature. He is also co-editor of Dermanities (dermanities.com), an online journal devoted to the humanities as they relate to dermatology.
As dermatologists we all have our individual styles of practice and favorite areas of dermatology on which we prefer to focus. But we all share one thing in common: We have a strong desire to improve our skills. Getting input from colleagues can help us achieve this goal. This column will highlight a wide range of pearls from practicing dermatologists — everything from a better way to perform a clinical procedure to a more effective method for communicating with patients to advice for improving an office function.
Tip 1: The Importance of Surgical Markings
An experienced physician or surgeon never underestimates the importance of pre-operative markings. These markings help delineate incision placement, anatomic landmarks, and areas of proposed treatment. Ideally, the markings should be made with the patient awake and alert in an upright and supine position. The patient should be made aware of the proposed markings and treatment areas prior to surgery by allowing him/her to inspect the surgical markings in front of a mirror prior to beginning a procedure. Documentation should also be made of this discussion by noting the following in the operative note:
Preoperative markings were made with the patient in front of a mirror. The patient was given adequate time to discuss the treatment plan, proposed risks, surgical markings, and areas of treatment while awake and alert prior to the initiation of the procedure. Surgical markers should also be durable enough to minimize the risk of accidental removal during surgery. In most cases, physicians employ commercially available sterile surgical markers or non-sterile permanent markers found in most office-supply stores. During smaller office-based cosmetic procedures, such as injectable fillers or other minimally invasive procedures, the use of permanent or semi-permanent markers may become prohibitive. The markers are usually not easily removable after the procedure and may further aggravate patients who must leave the clinic with telltale signs of having undergone a cosmetic procedure…blue and purple lines on the face. Our office has attained enormous success with preoperative markings using a clever and commercially available alternative to conventional surgical markers. We utilize a white-colored soft eye pencil (Rimmel) that is usually purchased at a beauty supply store. The make-up pencil allows easy identification of proposed treatment areas and is easily removed using tissue paper or gauze after treatment. In addition, the ingredients are rarely allergenic and are durable enough to withstand the duration of a smaller treatment. We have not had experience using the pencil with procedures requiring betadine preparation or longer operative duration. Of note, there are several types of eyebrow pencils marketed for commercial use. We have found that the soft eye pencils are far superior to the hard eye pencils in terms of overall durability as well as ease of removal. Raffy Karamanoukian, MD Hratch Karamanoukian, MD Santa Monica and Beverly Hills, CA
2: Apologizing for Running Late
Recently I went to a dental appointment, and when told she was running 30 to 40 minutes behind, I told the reception that I was going home and would rebook another time. That evening the dentist called me to personally apologize and explain that she values my time and that she was running late due to various unforeseen circumstances. Because of her phone call and kind gesture, I will stay in her practice. I will also personally call and apologize to any future patients who I am told left because I was running late. It is common courtesy (or perhaps not common enough), and it makes good business sense. Benjamin Barankin, MD, FRCPC Toronto, Canada
Tip 3: Cyclosporine Pearls
• Check baseline blood pressure and creatinine twice.
• Get fasting lipids.
• Initially examine patient, then check blood pressure every 2 weeks, then every month.
• Rule out active infection.
• Check serum potassium, magnesium and uric acid.
• Give patients magnesium supplementation.
• Let patient know they might experience acral tingling.
• Dose adequately and expect to give 4 mg/kg to 5 mg/kg.
• There are several versions of cyclosporine that include: 1.) Pill form — Neoral, Sandimmune, or Gengraf (which is similar to Neoral). These come in capsules of 25 mg, 100 mg or 250 mg; 2.) Liquid form — Neoral or SangCya, an oily liquid of 100 mg/ml; 3.) An intravenous form; and 4.) Topical form available as Restasis eye drops for dry eye. Note: Sandimmune and Neoral are not interchangeable at equal doses.
• Half-life is 5 to 18 hours, so it clears more quickly that any biologic. Specifically, half-life ranged from 6.3 hours in healthy volunteers to 20.4 hours in patients with severe liver disease.
• While many take it with apple or orange juice as this may improve taste, levels of SangCya (which has had marketing issues) can be changed by apple and orange juice.
• Giving it with grapefruit boosts its levels but the level increase can be hard to monitor.
• Risks of nephrotoxicity and hypertension increase with increasing duration of use.
• Do not expect to use it for more than 6 months or with phototherapy.
• It is not a medication of choice for obese patients or hypertensive patients.
• If you keep to monitoring guideline, creatinine will increase more than 30% only rarely.
• Transplant patients take 7 mg/kg to 15mg/kg — extrapolating their side effects to psoriatics is unclear.
• If a patient is NPO pre-op and post-op, give cyclosporine intravenously.
• When a patient is NPO pre-op and post-op, consult surgeon and nephrologist. Noah Scheinfeld, MD, JD New York, NY
Tip 4: Dermatologist, Watch Your Breath
Doctors may keep their clinic in order but may miss out on simple things like personal appearance and mouth odor. A well groomed appearance definitely soothes the sufferer, but what may be most annoying for patients is foul odor emanating from the doctor’s mouth. This is mainly due to overwork and not eating for long periods. Some foods like onions and garlic can emit a very strong odor, disagreeable to many patients. It also goes without saying that smell of tobacco or alcohol may have negative effects in dealing with a patient. Some of this can be avoided by being aware of the problem and taking steps to get over it. Khalid Al Aboud, MD King Faisal Hospital, Saudi Arabia
Tip 5: Humorous Answers to Patients’ Questions
1. After a minor procedure such as a shave biopsy, I’m sometimes asked, “Can I drive home after this?”
My response is, “Do you have a drivers license?”
Another variation is, “Can I shower after this?”
My response is, “Do you have indoor plumbing?” 2. Often, parents persistently ask me how I can “cure” their son’s or daughter’s warts.
My two responses are:
1. “If I knew how to ‘cure’ a wart, ie, cure a viral infection, I’d probably win the Nobel Prize.”
2. “Skin cancer is easy; warts are really tough!”
Herb Goodheart, MD Poughkeepsie, NY Dr. Barankin is a dermatologist based in Toronto, Canada. He is author-editor of five books in dermatology, and is widely published in the dermatology and humanities literature. He is also co-editor of Dermanities (dermanities.com), an online journal devoted to the humanities as they relate to dermatology.
As dermatologists we all have our individual styles of practice and favorite areas of dermatology on which we prefer to focus. But we all share one thing in common: We have a strong desire to improve our skills. Getting input from colleagues can help us achieve this goal. This column will highlight a wide range of pearls from practicing dermatologists — everything from a better way to perform a clinical procedure to a more effective method for communicating with patients to advice for improving an office function.
Tip 1: The Importance of Surgical Markings
An experienced physician or surgeon never underestimates the importance of pre-operative markings. These markings help delineate incision placement, anatomic landmarks, and areas of proposed treatment. Ideally, the markings should be made with the patient awake and alert in an upright and supine position. The patient should be made aware of the proposed markings and treatment areas prior to surgery by allowing him/her to inspect the surgical markings in front of a mirror prior to beginning a procedure. Documentation should also be made of this discussion by noting the following in the operative note:
Preoperative markings were made with the patient in front of a mirror. The patient was given adequate time to discuss the treatment plan, proposed risks, surgical markings, and areas of treatment while awake and alert prior to the initiation of the procedure. Surgical markers should also be durable enough to minimize the risk of accidental removal during surgery. In most cases, physicians employ commercially available sterile surgical markers or non-sterile permanent markers found in most office-supply stores. During smaller office-based cosmetic procedures, such as injectable fillers or other minimally invasive procedures, the use of permanent or semi-permanent markers may become prohibitive. The markers are usually not easily removable after the procedure and may further aggravate patients who must leave the clinic with telltale signs of having undergone a cosmetic procedure…blue and purple lines on the face. Our office has attained enormous success with preoperative markings using a clever and commercially available alternative to conventional surgical markers. We utilize a white-colored soft eye pencil (Rimmel) that is usually purchased at a beauty supply store. The make-up pencil allows easy identification of proposed treatment areas and is easily removed using tissue paper or gauze after treatment. In addition, the ingredients are rarely allergenic and are durable enough to withstand the duration of a smaller treatment. We have not had experience using the pencil with procedures requiring betadine preparation or longer operative duration. Of note, there are several types of eyebrow pencils marketed for commercial use. We have found that the soft eye pencils are far superior to the hard eye pencils in terms of overall durability as well as ease of removal. Raffy Karamanoukian, MD Hratch Karamanoukian, MD Santa Monica and Beverly Hills, CA
2: Apologizing for Running Late
Recently I went to a dental appointment, and when told she was running 30 to 40 minutes behind, I told the reception that I was going home and would rebook another time. That evening the dentist called me to personally apologize and explain that she values my time and that she was running late due to various unforeseen circumstances. Because of her phone call and kind gesture, I will stay in her practice. I will also personally call and apologize to any future patients who I am told left because I was running late. It is common courtesy (or perhaps not common enough), and it makes good business sense. Benjamin Barankin, MD, FRCPC Toronto, Canada
Tip 3: Cyclosporine Pearls
• Check baseline blood pressure and creatinine twice.
• Get fasting lipids.
• Initially examine patient, then check blood pressure every 2 weeks, then every month.
• Rule out active infection.
• Check serum potassium, magnesium and uric acid.
• Give patients magnesium supplementation.
• Let patient know they might experience acral tingling.
• Dose adequately and expect to give 4 mg/kg to 5 mg/kg.
• There are several versions of cyclosporine that include: 1.) Pill form — Neoral, Sandimmune, or Gengraf (which is similar to Neoral). These come in capsules of 25 mg, 100 mg or 250 mg; 2.) Liquid form — Neoral or SangCya, an oily liquid of 100 mg/ml; 3.) An intravenous form; and 4.) Topical form available as Restasis eye drops for dry eye. Note: Sandimmune and Neoral are not interchangeable at equal doses.
• Half-life is 5 to 18 hours, so it clears more quickly that any biologic. Specifically, half-life ranged from 6.3 hours in healthy volunteers to 20.4 hours in patients with severe liver disease.
• While many take it with apple or orange juice as this may improve taste, levels of SangCya (which has had marketing issues) can be changed by apple and orange juice.
• Giving it with grapefruit boosts its levels but the level increase can be hard to monitor.
• Risks of nephrotoxicity and hypertension increase with increasing duration of use.
• Do not expect to use it for more than 6 months or with phototherapy.
• It is not a medication of choice for obese patients or hypertensive patients.
• If you keep to monitoring guideline, creatinine will increase more than 30% only rarely.
• Transplant patients take 7 mg/kg to 15mg/kg — extrapolating their side effects to psoriatics is unclear.
• If a patient is NPO pre-op and post-op, give cyclosporine intravenously.
• When a patient is NPO pre-op and post-op, consult surgeon and nephrologist. Noah Scheinfeld, MD, JD New York, NY
Tip 4: Dermatologist, Watch Your Breath
Doctors may keep their clinic in order but may miss out on simple things like personal appearance and mouth odor. A well groomed appearance definitely soothes the sufferer, but what may be most annoying for patients is foul odor emanating from the doctor’s mouth. This is mainly due to overwork and not eating for long periods. Some foods like onions and garlic can emit a very strong odor, disagreeable to many patients. It also goes without saying that smell of tobacco or alcohol may have negative effects in dealing with a patient. Some of this can be avoided by being aware of the problem and taking steps to get over it. Khalid Al Aboud, MD King Faisal Hospital, Saudi Arabia
Tip 5: Humorous Answers to Patients’ Questions
1. After a minor procedure such as a shave biopsy, I’m sometimes asked, “Can I drive home after this?”
My response is, “Do you have a drivers license?”
Another variation is, “Can I shower after this?”
My response is, “Do you have indoor plumbing?” 2. Often, parents persistently ask me how I can “cure” their son’s or daughter’s warts.
My two responses are:
1. “If I knew how to ‘cure’ a wart, ie, cure a viral infection, I’d probably win the Nobel Prize.”
2. “Skin cancer is easy; warts are really tough!”
Herb Goodheart, MD Poughkeepsie, NY Dr. Barankin is a dermatologist based in Toronto, Canada. He is author-editor of five books in dermatology, and is widely published in the dermatology and humanities literature. He is also co-editor of Dermanities (dermanities.com), an online journal devoted to the humanities as they relate to dermatology.
