[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today I am very excited to be with Dr. Irwin Braverman. Dr. Irwin Braverman is Professor Emeritus of Dermatology at Yale University. He received his undergraduate degree from Harvard College and his MD from Yale University in 1955, and he also trained as an intern, resident, and fellow at Yale as well as Yale New Haven Hospital and Medical Center. He is board certified in dermatology as well as dermatopathology, and he retired from being a full-time faculty member in my current department of dermatology in 2010 after 48 years of service. His research focused on the cutaneous microcirculation, cutaneous T-cell lymphoma, as well as aging, and he is the very well-known author of Skin Signs of Systemic Disease, a book that really taught more than one generation of dermatologists and doctors to really think about what the skin would and could tell you about a patient. I also had the luck of first hearing Dr. Braverman speak when I was a resident at University of California, Irvine, when he came to give a talk on visual recognition, and observation, and how visiting art galleries and doing observational work on paintings can help you be a better observer and better doctor. I am really excited to be here with Dr. Braverman today.
[00:01:31] Irwin Braverman: Nice to be with you, Christine.
[00:01:34] Christine Ko: Thank you. Thanks. Okay, would you just share a personal anecdote about yourself?
[00:01:41] Irwin Braverman: Paul Beeson, when he came to be Professor of Medicine, Head of the Department here, you would go on rounds with the Professor, and you would present a case to him. And the first thing that he did was he sat down on the bed beside the patient and was talking to them about everything except their illness. It was unbelievable. And, then he finally got around to why they were there. That made a lasting impression. And the reason, I realize now why he did that, because he didn't do it as a teaching method, he did it because that was him. Before he had come to Yale to be the Head of the Department, he had been in practice with his father and his brother for a number of years in a general practice in Ohio. And so he brought with him this clinical sense of how you really work with people who were sick. He just did it naturally, and we were all blown away by it. I think it was the best lesson I ever got.
[00:02:47] Christine Ko: So once you saw him doing that, you learned to do that?
[00:02:51] Irwin Braverman: I learned to do that. I realized that you're coming to medical school to solve problems. You like to solve problems. You like to solve puzzles. That's true. But we never thought of them really as a person who happened to have a puzzle to be solved.
[00:03:10] Christine Ko: Yes. That's a wonderful story. As I said in your bio, you worked full-time in dermatology for 48 years, and you're still working. You still come to our grand rounds, and you still participate in various ways in our department. I wanted to ask you if you have any lessons or advice regarding avoiding burnout and having a long and productive career.
[00:03:38] Irwin Braverman: Today the word burnout applies to people who are giving up because of the inordinate oversight by insurance companies and electronic health records, being forced to see a quota of patients within a prescribed time, and requirements of documentation that never were required before. That takes all the fun out of medicine that we all used to enjoy.
[00:04:06] I went on a sabbatical in '69. Yep. My wife said that was the first time in years that I actually got to live with my family, and live with my children, and my children got to know me, other than this person that had piles of stuff sitting on the dining room table, writing a book or something. I think today, young doctors have more sense and are trying to spend time with their family, which is very important. But we didn't do that. We were so intent on establishing either a career or a practice that it really took away from family. If I had to do it all over again, I’d probably end up doing the same thing that I did, then; I would do it as I did then. The problem is if you're in academic life, you need to establish yourself early, and then you can get the family into this whole situation. But if you don't do that, then you are really not going to get anywhere in academic medicine. That's a problem. And I don't know how to solve it because you have to do both. You can't really do both if you want to succeed, unfortunately, in academic life. I have no solution except try to get it in early so you can spend the rest of your life with your family. It's a tough choice.
[00:05:29] Christine Ko: So it's interesting because you commented that if you had to do it all over again, though, you probably would do it the same way.
[00:05:37] Irwin Braverman: Yes. I don't see any other way around it. You're either serious about an academic career or you're not. And if you really are serious about an academic career, it does mean a lot of sacrifice on the part of your family to be able to establish yourself.
[00:05:56] Christine Ko: Yeah. I always thought it was hard, for any parent. It is probably truly impossible to really do both at the same time. The way that I was first introduced to some of your work is, as I said, when you came to UC Irvine to give a lecture about the work you do with artwork and museums. You were advocating improving diagnosis and visual recognition through observations of artwork. Can you talk about that a little bit?
[00:06:24] Irwin Braverman: In 1998 or something, I was thinking, over all these years, I only recall about a half a dozen residents, who at the time they finished, had figured out what I was doing and were able to be as good observers as I was. And how come? What was happening was that when I pointed things out to them instead of their trying to figure out how I arrived at that conclusion, they were simply memorizing. They weren't doing any analytical work, they were just memorizing. And I thought, maybe a way to get around it is if I show them something they have no experience with, they have no prejudice of biases toward this, and it's a foreign object to them. They would probably tell me everything that was there.
[00:07:13] Now I'm thinking a foreign object. How about a painting that would be a foreign object? And so I took the residents to the museum a few weeks later and had them look at paintings and tell me what they saw. And then, the residents were actually doing a better job of describing things. And I thought this would be good, not just for dermatology residents; we really should be working with first year medical students to get them into this mode of looking carefully. And so I went to the Dean of Students and told him [it was Bob Gifford], and he liked the idea.
[00:07:54] The backstory is that you would think that this skill of looking carefully at the patient, not just the skin, but looking carefully at the patient, would've been something that would've been instilled in us when I began medical school. But what was emphasized was called inspection, when you did a physical exam. The catch was that what we were inspecting for, we were told what to look for in advance. Make sure that the patient isn't yellow, the patient isn't pale, the patient doesn't have some unusual pigmentation or something. And after you've done that, then you go on listen to the heart, the lungs, and everything else. So we were not taught to really look carefully. We were taught to look for specific physical findings that would be part of some disease. After you got out in practice, just through experience, physicians could see things that they hadn't been taught before.
[00:09:01] We started this program and within three months of this pilot program, word got out through the museum network. Other schools really caught on and it struck a vibe, and after all these years, it's almost 25 years, we have at least a hundred medical schools in this country that are doing this, one way or another. And we have a whole bunch overseas, doing the same thing.
[00:09:29] Christine Ko: That's amazing. It's a different way of thinking about it, right? Because as you said initially it was like, look for this, look for yellowing of the skin, look for paleness of the skin. That's important too, but it's also important, as your program has shown, and the people all over the world adopting similar programs of their own, that it's also important to look with an unbiased manner, too.
[00:09:56] When you said you were teaching residents and medical students and wanting them, by the end of residency, to be able to observe the way you do. How did you teach yourself to be such a good observer?
[00:10:11] Irwin Braverman: Let's see. I'm basically a visual person. I like to look at things, and I always like to draw, and I always like to go to museums to look at things. The niche that really got me was electron microscopy. I said, I really love this stuff because the electron micrographs really look like a piece of art, not as scientific information, but it was beautiful to look at.
[00:10:41] Of course when you're looking, you're also listening. When talking about observational skills, we're not just really talking about vision, we're talking about auditory skills too. What is a person saying? How is he saying it? What is he not saying? And so when we take the students to the museum and show 'em paintings and go through this exercise, I also always stress these other senses that you need to be aware of, that you should be using at the same time.
[00:11:12] Christine Ko: I love what you just said because it took me a long time to look and really observe. It's a skill, and I can improve it. Also the listening piece too. I can listen better, and I have improved a lot. It's a skill, and the two together compliment each other for sure, and get you to a better answer, almost all the time. The third piece for me, actually, was what's commonly called emotional intelligence. You can see emotion in people, their facial expression, but you can also hear emotion too, right? In someone's voice, even on the phone or whatever. You can tell if they're smiling, even. Do you have thoughts on that, on emotional intelligence or the perception of emotion?
[00:11:56] Irwin Braverman: This term, emotional intelligence. President of Yale, Salovey, was a big proponent of this and did a lot of research on this. Being empathic is part of having emotional intelligence, and you have to learn how to control the emotions that may have suddenly come up in your system when you're looking at something. I think it's basically empathy. So the question is, can you teach empathy in medical school? Yes or no. People say, yes, it can be taught, but actually when they describe why they think you can teach it, what they're really saying is they've taught communication skills. We know the right words to say. It's communication. It's not really a deep feeling. Others are saying, no, it's an experiential thing for you to really learn what it means to be empathic or feel empathic. And I belong to that school. I don't think you can teach it. I think when doctors have something terrible happen to them personally or in their family, they then are able to relate to their patients in a really more truly empathic way. And I would certainly say that certainly happened with me. I understood that there were other things going on in a patient besides being ill. There was a lot else going on in family relations, et cetera. But I think you have to go through an experience to really appreciate that patients are going through an experience. Think of patients not as a puzzle to be solved that also walks and talks, but think more of patients as a human being that happens to have some problems. I think you can only do that through experience. I don't believe you can possibly teach anyone to do that. I think you can get them to appreciate that there's something more to the patient than a collection of symptoms.
[00:14:05] Christine Ko: Do you have any final thoughts?
[00:14:08] Irwin Braverman: I would do it all over again. I have no regrets. Other than that, it's been a great adventure, and it continues.
[00:14:15] Christine Ko: It's amazing and wonderful that you don't have regrets. Hopefully all of us as doctors and patients and human beings can live our lives to just do the best we can and not have regrets. You have been a huge influence on me from when I was a resident. It's really been an honor to be in the same department as you.
[00:14:40] Irwin Braverman: Thank you. That's very nice of you, to say.
