Subscribe
Share
Share
Embed
The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Victoria Barbosa talking about clinical excellence in dermatology.
[00:00:13] Dr. Barbosa: With a more diverse physician workforce, we are all better doctors. I've got colleagues who were of Jewish descent, of Indian descent, you know, African descent from Africa, me African descent born in America, etc.
So we all come together, and I learn lots from my colleagues, and hopefully, they learn something from me. And so we are all better equipped to take care of all patients because of the diversity.
[00:00:42] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Victoria Barbosa. Dr. Barbosa is an associate professor of dermatology at the University of Chicago, where she serves as director of the Hair Loss Program in the section of dermatology. She's an expert in the areas of alopecia and in treating skin diseases in people of color. She currently serves as President of the Skin of Color Society, a professional dermatologic association, and vice president of the Illinois Dermatologic Society. She is also a past president of the Chicago Dermatological Society. Dr. Barbosa is passionate about nurturing others on the path to being a physician. She serves on the executive committee of the Pritzker School of Medicine admissions committee and is co-head of Pritzker's Lewis Society, one of the four societies here where she serves as a career advisor to over 40 students per year. Vicki, thanks so much for joining me.
[00:01:59] Dr. Barbosa: Thank you for having me.
[00:02:00] Dr. Cifu: With all of those things you do, it's hard to imagine that you actually have time to be sitting here for an hour, so thank you again. So I want to start very broad. You're a dermatologist with a particular specialty in hair and hair loss. How did you come to sort of this subspecialty within dermatology?
[00:02:19] Dr. Barbosa: So, alopecia is really interesting because it sits at the intersection of medicine, culture, and cosmetic science.
[00:02:29] Dr. Cifu: Right.
[00:02:29] Dr. Barbosa: Right? So the decision to pursue dermatology really happened during medical school. I'm a visual person. I loved that we could treat all ages. I loved that it was medical and surgical. So that made sense. Culture, well, particularly for Black women, hair care, skincare, all of that is really part of the fiber of our being. So finding an area within medicine where interest and knowledge about how culture and cultural practices impact disease, fantastic.
And then as circumstance would have it, I actually worked in the cosmetics industry as a VP in R&D for seven years after my fellowship. So, this really is the meeting of all of my areas of interest. However, the path appears more direct than it actually was. And what I would say is I was really following my passion and taking advantage of opportunities that came along the way.
[00:03:34] Dr. Cifu: Yeah. Yeah. That's so great because I mean, I think so many people, when they are happy with what they do, they, to some extent, lock into those fields that combine– You know, everybody has multiple distinct interests, right? And you seem almost like, you know, the poster child for, okay, how do I bring everything into one clinical activity?
So I want to specifically, obviously talk to you about your hair loss practice, which I just find so interesting on so many levels. And you like got a question ahead of me by sort of noting these because there's kind of the dermatologic issues, there's the medical dermatologic overlap with it. And what I think is probably something I can really learn from you is that you spend time managing patients who have these really psychologically devastating problems, which are often not a threat to their health, okay? Obviously, there are certainly very serious, dangerous, morbid conditions, which also affect hair, but there are a lot which don't. And it's interesting that a lot of the weights of this problem are sort of, I don't know, you know, societally-induced or just have to do with cultural norms. And so I kind of wonder, like, what have you learned about managing the anxiety and distress that must be really common with a lot of your patients because of this?
[00:05:03] Dr. Barbosa: So you've really hit the nail on the head, right? I often joke with my patients. I'm not saving any lives in hair loss clinic. However, I think that people in general and physicians specifically underestimate the psychological impact that alopecia has. And what's interesting, one of the many interesting things about hair loss clinic is that the degree of anxiety, depression, distress, is not necessarily correlated with the amount of hair loss that a person has.
[00:05:38] Dr. Cifu: Right, right.
[00:05:40] Dr. Barbosa: So I have learned so much by having an alopecia practice. And at this point, about 90 percent of my patients are alopecia patients. And just to mention a few things that I've learned in managing these patients. One is to always be honest and hopeful with patients, right? So there's non-scarring alopecia where we may stand to bring a good amount of hair back, but some of my, a lot of my patients have scarring alopecia where regrowth is going to be a little more modest. That doesn't mean that we can't try. Right? And I think this is a lesson that extends to even, you know, more impactful health conditions. Patients always want to know that they tried and people can accept almost any outcome if they feel seen and heard and they've attempted to make things better.
What's been really important in my clinic is participatory decision-making.
[00:06:48] Dr. Cifu: Okay.
[00:06:48] Dr. Barbosa: And this is easier because I'm not saving any lives in hair loss clinic, but I think the concept works even when you are actually saving lives. What I find is that I give patients options and sometimes medical options really resonate with people right away and they'll say, "I'll do everything you say, doc." Right? And sometimes they want to try it their way first. Right? So I can say, "Okay, you've got an inflammatory scarring alopecia. I want to do doxycycline or hydroxychloroquine and we'll sprinkle on some minoxidil and a topical steroid." And they say, "Whoa, whoa, whoa. I don't want all those medicines. I want to try rosemary oil."
I say, "Okay, here are the potential outcomes of your decision. And I'll see you in six months and we'll revisit it." And patients I think, in the long-term, are more apt to trust me and listen when I say, "Okay, we tried your way. Let's try mine." And it just makes for a better relationship. And I would say the third really important thing that I would just highlight is really paying attention to the patient's level of health literacy when I communicate, right? So I have extremely sophisticated patients, right? Like all of us here at the University of Chicago, some of my patients are department chairs, whatever, right? They come to me with the latest literature, "Here, doc, I printed this out for you in case you hadn't seen it."
[00:08:18] Dr. Cifu: "And here's my analysis of the study."
[00:08:20] Dr. Barbosa: "Highlighted," right? You know, post-it notes. And then there are some people who don't even know that alopecia just means hair loss. And being able to communicate the same information to people at different levels where they don't feel that you're talking down to them, but they feel respected, I think the importance of that has really been driven home to me.
[00:08:44] Dr. Cifu: I love listening to you talk about that because, you know, it's so clear, the parallels in, I think, sort of any medical practice, and the thing which maybe stuck out to me so clearly is the balance of hope and honesty when you're counseling people. I feel like that's something that I personally feel like I've gotten better at as my career has gone on because I'm able to be a little bit more definitive and confidently definitive in like, "Look, this is what we have."
"This is what the outcomes are likely to be." I can sort of foresee the future to some extent. And therefore, I can be very honest with, you know, the sort of normal distribution of outcomes that people have expected. Is that something you feel like you've grown in your career with, or is that something which, given the field, was very clear to you upfront?
[00:09:42] Dr. Barbosa: No, I definitely agree. That's something– It's a skill that I have developed over time. And part of it is learning to be comfortable delivering difficult news. And I think there is a way to do that with all care and concern and sincerity, and authority so that people can hear it. It's really hard sometimes for me because– Particularly because many forms of alopecia are disproportionate in Black women, and partly because I'm a Black woman so some people seek me out. I've got a large percentage of my population are people who have really delayed seeking care. Right? Partly because they were busy taking care of their kids, their grandkids, their parents, partly because they didn't know who to go to, they didn't even know dermatology. And partly because when they sought care from other physicians, you know, if you go to your primary, but your diabetes is not controlled, your hypertension is not controlled, alopecia is not making its way into the visit.
So I get people, there are a lot of tissues in alopecia clinic because people say, "I'm finally ready to prioritize myself. I finally found the right place to be. I'm ready to have my hair back." Right? And sometimes it's not all coming back and sometimes none of it's coming back and we're just trying to keep it from getting worse. And so there is a real skill, right? To helping those patients come to terms with things, and it's also, it comes from what primary care doctors have more naturally, which is a really in-depth relationship over time with people, and you know, I'm honest with them at every point along the way, but it's sometimes heartbreaking to watch their realization that maybe it was– You know, they've waited too long.
[00:11:43] Dr. Cifu: It was interesting when I was preparing for this, you saw some of this, I changed my planned questions multiple times, which I think was a clue to me that I had so much that I was interested in learning from you. And one of the things you said, which I'll probably take away, and I'd like to sort of get your idea of how to deal with it. So I see, you know, plenty of patients who, as you say, I'm taking care of, you know, multiple issues on, and I will notice an issue, and for you, you know, it's a dermatologic issue, often it's a hair issue, which they're not bringing up at the visit, right? And I don't know if they're not bringing it up because they don't feel comfortable bringing it up, because it's not important, because in a way they're obsessed with the other issues, right? That I am. For me in primary care, I'm kind of happy to, you know, put something like that, that I really know nothing about, and I'm going to do a bad job taking care of, you know, to Dr. Barbosa's clinic but I'm always a little torn, you know, when do I step in to raise issues that the patient's not raising with me? And I was wondering, given your experience with this problem, you know, what advice do you have?
[00:12:57] Dr. Barbosa: So that's a great question. There are some conditions in dermatology where it's– You can assume the patient knows they have the condition. You can assume that they know to go to the dermatologist if it bothers them. So I imagine, some of your patients might come in, have some acne on their face, but they don't bring it up to you.
No big deal because they know to go see the dermatologist if it bothers them. The challenge with alopecia is that patients don't know that treatment is available and they don't know who to go to to get treatment. And so it is one instance where it's probably worth an off-hand mention, particularly, if the alopecia is severe. Now, if the alopecia is severe, you might not know. They're probably concealing it pretty well but at least an off-hand mention, "Hey, by the way, I noticed XYZ. Would you be interested in seeing someone about that?" is more worthwhile perhaps than for other areas of dermatology because patients' knowledge and awareness of what can be done is just very low.
[00:14:12] Dr. Cifu: Yeah, right. Sort of "Oh, I noticed this, this looks like X. Are you interested in addressing it?" Interesting. And then the last question before I pivot a little bit, and this is again, I think something that we have a parallel in, right, is that there are a lot of problems I take care of that people's sort of, let's call them self-care habits play a role in their problems. I think it's probably true for you. And I'm thinking about things like traction alopecia and habits and, you know, products and stuff. Does that raise tension in the visit or that's generally just an educational thing where you say, "You know, I think part of it is something that we can easily fix because of what you're doing."
[00:15:01] Dr. Barbosa: So that's a very comfortable conversation for me to have. My goal is for it also to be a comfortable conversation for my residents to have. It's comfortable for me because I'm well aware of the hairstyling practices. I know the difference between cornrows and box braids and crochet versus a sew-in versus K-tips or I-tips.
[00:15:27] Dr. Cifu: Right, right.
[00:15:27] Dr. Barbosa: And you need that comfort to then even be able to say, "Hey, can I examine your scalp? Can I look between the tracks to see what's going on?" So I think that's part of the comfort and this is– You actually have served up your own pivot beautifully but–
[00:15:42] Dr. Cifu: I was thinking the exact same thing.
[00:15:47] Dr. Barbosa: So that's comfortable and a necessary conversation for me. You know, it's fun when we do the educational sessions with residents. One of the sessions I did last year was bring in a bag full of hair from the beauty supply store to say, "Okay, this is what crochet hair looks like. This is what braid hair looks like. This is what the different styles look like," because a lot of care is, you know, centered in cultural humility and knowledge. And that can be taught.
[00:16:16] Dr. Cifu: Right. So my next question, which you sort of got to with that, I do want to ask you about the issue of sort of, you know, race concordance and race discordance in doctor-patient relationships.
There's terms that I'm not crazy about, but it is sort of what the literature is. You know, you're an African American woman working in dermatology. You have a specialty, you know, in hair and hair loss. And clearly from what you say, it's something you think about, especially in your education role, right? Where although we're doing much better than we used to, you know, we're still not great at having medicine reflect the population we take care of. So besides the importance in education, which I'm certainly happy to have you speak to, just what you see as far as, you know, doctors taking care of patients and when people do this well, when people do it badly, how it affects your care. I realize you could probably talk for, you know, a month on that, but just teeing you up.
[00:17:20] Dr. Barbosa: Sure. So, unfortunately, the literature on race-concordant care in dermatology is fairly sparse compared to the more robust medical literature on the same topic but we do see some common themes, including a preference for race concordance among Black patients, including belief that there's an increase in participatory decision-making and increased comfort with the greater likelihood to adhere to the treatment plan, et cetera.
[00:17:55] Dr. Cifu: Got it.
[00:17:56] Dr. Barbosa: But I think that the issue– Oh, oh, let me say this, and we know that dermatology, where one might argue that cultural competence is particularly important is one of the least diverse specialties in medicine, right? We know that. I think the issue is bigger than having enough Black doctors to take care of Black patients and enough Latin doctors to take care of Latin patients.
I think the issue is that with a more diverse physician workforce, we are all better doctors. Right? So I'm really fortunate because I'm here and we have a really diverse section. So I've got colleagues who are of Jewish descent, of Indian descent, you know, African descent from Africa, me, African descent born in America, et cetera, right?
And we all learn from each other. People, you know, literally from Europe, white folks from the U. S.– It's just, so we all come together and I learn lots from my colleagues and hopefully they learn something from me. And so we are all better equipped to take care of all patients because of the diversity.
[00:19:17] Dr. Cifu: I love that point because I certainly feel, and people can't see us, but like, I'm a bald white guy here, right? In this conversation. I find it interesting when I bring colleagues and trainees into the room, right? Who are, let's say, race or hair discordant from myself, right? And it's interesting how quickly that becomes a different collegial conversation on some topics because when we bring a third person in the room, right? Who may not look like or sound like or have the background to the patient, me, it really does often enrich the conversation and maybe takes away a little bit of the tension that may be built, you know, given the bubbles that a lot of us live in and the rest of our lives.
[00:20:12] Dr. Barbosa: One of the things that's really wonderful about being at the University of Chicago and practicing in an underserved area for me as a Black woman is that I get to bring my most authentic self to most, really, all because, you know, at this age, what are you going to do, of my patient interactions. Right? And so if there are cultural commonalities, if we both went to the same concert last night, if we both have the same braider, that is part of the conversation that helps me establish a really meaningful relationship with my patients. More often than not, the resident in the room, the med student in the room with me is race discordant, not always but I hope that what they take from those interactions, the most important thing really is bringing your authentic self as a physician who is, you know, in a recognized position of authority, but also there to be helpful to bring that self to the visit. And so that is one of the things I hope people, you know, as students and residents take away from my interactions. Now, I will say, every now and again, every now and again, it will happen that I'll be in the room with a Black patient and we'll have a Black resident and a Black med student and it's cause for celebration. I mean, the first time it happened, the patient let out a shriek because she didn't know I was Black. So when I came in and it took me a minute to process what was happening, it was a shriek of joy and her feet were kicking on the exam table. It was really a very sweet moment.
[00:22:06] Dr. Cifu: Yeah. Do you point out– It's one more, I think, question for my own you know, medical education side, you know, we spend a lot of time teaching the medicine itself, right?
And we recognize that we're also doing a lot of modeling, right? And we tell students, especially as they're entering their clinical year, like, you know, "Watch everything. You'll find things that are going to work for you, that you can sort of model. You're going to see some people who do things which maybe they'll model in reverse, that you'll say, wow, that's something I'm never going to do."
You're in a position where there are conversations going on that probably won't go on in other activities that they're doing during third year. Do you point out that more, I want to call it like sort of softer role modeling, right? It's not the teaching of the medicine, but it's teaching, "Hey, did you notice this in the communication style?"
[00:23:11] Dr. Barbosa: I absolutely do. I'm keenly aware that the majority of the students, particularly who rotate with me, are not going to go into dermatology, let alone be alopecia practitioners, but I do think that, and I've heard this from students, that they see, I have a really wonderful, special bond with my patients.
And I point out the things that I do in the visit to sustain those relationships, to develop and sustain those relationships. And I think that that is as important to teach, almost as important to teach as medical knowledge.
[00:23:52] Dr. Cifu: Yeah. I, A, agree with you. And B, I think it's one of those things, you know, that kind of can't be done in the classroom, right?
It has to be done with actual people, you know, coming for actual care and seeing how they respond. So I would sort of just put an underline on that because I just think it's so critical.
Vicki, I want to thank you again for joining me. I know you're busy and this has been so terrific, covered so many topics that I was interested in. I will almost certainly lean on you in the future for something else.
Thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute webpage.
The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.