Best Practices in Managing Atopic Dermatitis in Skin of Color - Episode 3
Drs Bhatia, Lamb and Noor talk about the importance of building trust with patients and highlight topics to discuss with patients and parents.
Neal Bhatia, MD: I want to switch gears and talk about kids, talking to patients and their parents, as well as building their trust. Angela, I’ll start with you, what barriers do you see dermatologists have in terms of building up trust? Omar brought up a good point about getting different ethnic groups and different skin types into trials. Even more so, everyone has an obstacle on moving forward, what obstacles do you see we all face?
Angela Lamb, MD: Absolutely, there are definitely obstacles. Let’s again look at the epidemiology here. Atopic dermatitis definitely impacts Black children more; we’re looking at about 19% vs White children at 16%. That’s even when we looked at factors like socioeconomics, we took all of those variables out, and it really is a higher burden. We want to get that trust; we want to make sure that parents are actually going to do the things that we recommend. I think the first thing is trying to understand the story and understand what they’re using. Feedback I get from patients of color often is that, one, “The person didn’t even touch me or my child. A doctor came into the office and just stood across the room and didn’t even touch me.” That I think is really a big trust builder for people of color. Then the second one is that they didn’t listen, “They didn’t hear my story.” They didn’t hear what they’re doing, because a lot of times I find a parent is actually doing some things right. In the Black community specifically, Vaseline is pretty popular in our community, and it’s one of the best emollients out there. A lot of times, they’re already doing things right. There are other things, like using black soap, that aren’t so great, but they sometimes have some excellent tools that they’re already using.
Trying to marry what they’re doing with some new things that we know work is important.
Particularly for young children, wet wraps, copious emollients, and taking baths, we know aregreat for atopic dermatitis. Then if you do feel like they need one of these systemic medications, it’s talking them through that. The biggest thing I get from patients of color is a lack of trust with the medical community. The thought of using something that’s going to be injected, or a pill, is higher on their radar than just putting on creams. I really try to, as a physician of color, say, “If this were my child and they were suffering like this….” Another phrase that I use to build that trust is to say that the itching and scratching burden, and what that does to your child’s body, is far more harmful than any of the adverse effects of these medications that we’re going to be giving. Those are just a few of things that I try to do and things I think we should keep in mind.
Neal Bhatia, MD: Those are excellent, especially putting it in the context of what would you do with your own kids and things like that. Omar, what would you add to that?
Omar Noor, MD, FAAD: I love everything Dr Lamb said. I think it’s really getting on the level of the patient. Neil, you mentioned initially that Dr Google and all of this information is out there, but what this kind of technological world has created is a patient who wants to be communicated with. Long gone are the days, like you said Dr Lamb, of the physicians standing in the door saying, “This is what you have,” leaving in 30 seconds, and sending in a medical assistant to talk about their problem. They want the physician to be the driver of the communication. Therefore, we have to be able to communicate with the patient, and when you see enough patients, it’s amazing how well you can connect to someone, even if you don’t necessarily suffer from atopic dermatitis. Because we see enough people for them to appreciate that we know what they’re going through. I say, especially when working with pediatric patients, “I know your son, your daughter, they’re staying up all night. It’s difficult when my kids are sick and they stay up all night. Your kids aren’t sleeping appropriately, they wake up in the morning, they’re fussy, they’re annoyed, they’re not paying attention in school. Everyone is all over them, asking what is wrong with them? It’s because they’re itchy, it’s because they’re uncomfortable, and we have tools now, we have options, we have therapeutic options that can help them.” And they appreciate that dialogue.
Neal Bhatia, MD: Exactly. The door diagnosis is what we used to call it. You’re standing by the door, and somebody else will talk to you. It has to give way to us putting our hands on patients. We can’t think of this as a 2D [2-dimensional] diagnosis anymore, and telemedicine doesn’t serve us in that way. Even more so, we need to get involved in the routine to ensure compliance with the topicals. Angela, you brought up a good point about steroids and some of the risks that patients think they have, or the phobias that go along with steroids. In San Diego, I deal with a lot of patients who come in and say, “I want something natural.” I say, “Eczema is natural, how’s that going?” It makes it a little difficult.
We also have some of the worst water in the country. Parts per million of contaminants is horrible in Southern California. Getting patients to understand the importance of a water softener, a filtration system, shorter showers, things like that, is important. Then I have a lot of patients from Asia who are worried about foods, and their focus is entirely on foods. I say let’s put foods aside and think about some of the other nuts and bolts. To both of your points, getting the physician involved with compliance is probably the best driver for ensuring that things will go well. I always think about the patient’s co-pay and the deductible when we’re thinking about when do we want to see patients back. But getting them back a little sooner from the first visit and then spacing things out might help to bring some of that narrative home.
Transcript Edited for Clarity