Dr. Jennifer Stein is an expert in dermoscopy and diagnosis of melanocytic lesions. she is a mother as well as physician and shares her tips on continuous improvement. Dr. Jennifer Stein, MD PhD is a native New Yorker who grew up in Staten Island. She was an NYU medical student as well as dermatology resident, and she has been on the faculty at NYU Medical School since 2008. She specializes in melanoma care as well as general dermatology. Her efforts in patient care, teaching, and research were recognized in 2014, when she received the NYU School of Medicine’s Julia Zelmanovich Young Alumni Award. She is currently a Professor in the Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine. She also serves as the Director of the Dermatology Medical Faculty Group Practice. You can find her on Twitter @JenniferStein MD.
Dr. Jennifer Stein is an expert in dermoscopy and diagnosis of melanocytic lesions. she is a mother as well as physician and shares her tips on continuous improvement. Dr. Jennifer Stein, MD PhD is a native New Yorker who grew up in Staten Island. She was an NYU medical student as well as dermatology resident, and she has been on the faculty at NYU Medical School since 2008. She specializes in melanoma care as well as general dermatology. Her efforts in patient care, teaching, and research were recognized in 2014, when she received the NYU School of Medicine’s Julia Zelmanovich Young Alumni Award. She is currently a Professor in the Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine. She also serves as the Director of the Dermatology Medical Faculty Group Practice. You can find her on Twitter @JenniferStein MD.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm honored to be speaking with Dr. Jennifer Stein. Dr. Jennifer Stein has MD and PhD degrees, and she's a native New Yorker who grew up in Staten Island. She was an NYU medical student as well as a dermatology resident there, and she has been on faculty at NYU Medical School as well since 2008. She specializes in melanoma care as well as general dermatology. Her efforts in patient care, teaching, and research were recognized in 2014 when she received the NYU School of Medicine's Julia Zelmanovich Young Alumni Award. She's currently a Professor in the Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine. She also serves as Director of the Dermatology Medical Faculty Group practice. Welcome to Jennifer.
[00:00:47] Jennifer Stein: Thank you so much for having me. It's such an honor to be on because I love listening to your podcast, so I'm very excited to be talking to you.
[00:00:55] Christine Ko: Thank you. Would you share a personal anecdote about yourself with us?
[00:00:59] Jennifer Stein: Sure, so I have two children who are 14 and almost 11. A very important part of my family life is that my older son has autism. He's 14, almost 15. We've had a lot of challenges, but right now he's doing really well, and what we've had to learn to help Josh, which is my older son, has really helped us to become better parents. And also it's really helped me in being a dermatologist and taking even better care of my patients.
[00:01:28] Christine Ko: Thank you for sharing that. Yes, I knew that because one time, by luck, I got to sit next to you on a plane coming back from a meeting. My son was sitting next to me, and you sat on the other side of my son. All three of us hung out a little bit, and you shared with me about your son. My son is deaf and has cochlear implants. He's definitely had challenges with that. It really has made me a different and better person, although I'm still working on it.
[00:01:56] Jennifer Stein: I remember that flight really well because I'm a nervous flyer, and I was sitting next to your son, and he kept me so calm the whole ride. I was really grateful to be sitting next to the two of you on that flight.
[00:02:06] Christine Ko: Oh, I couldn't even tell that you're a nervous flyer. We touched on it a little bit, being mothers and mothering our children and also being physicians, and I think emotional intelligence comes into that. How do you define and use emotional intelligence?
[00:02:23] Jennifer Stein: I think emotional intelligence as being able to understand and to manage your emotions and emotions of people around you. Having to deal with my son and having to help my son has taught me tremendous amounts about emotional intelligence, much more than I ever knew or thought about before I ever had Josh. There's lots of strategies, and one is about dealing with unexpected challenges. What anybody can get very upset about is when you expect something to be a certain way, and then your whole day gets thrown for a loop. And my son, because of his autism, is used to things being a certain way, and he can be sometimes very rigid and very fixed about it. He really likes routines. Through many years, he's gotten much better at being able to deal with unexpected challenges. We practice them, he practice them at school, we practice them with the psychologist. So many of the things that he's learned, I feel like I can use in my life with patients, just in every day, being a leader. For example, just yesterday, we had two medical assistants call in sick at the last minute. It was this unexpected challenge.
[00:03:31] Christine Ko: Yes. A lot of what you said resonates with me. I got interested in emotional intelligence, with my kids. Initially I got interested in visual recognition and visual perception, which is very relevant to dermatology and dermatopathology. So this leads into my next question, which is how do you hone your visual perceptive skills? And related to that, how much do you think is talent versus hard work?
[00:03:54] Jennifer Stein: My specialty within dermatology is pigmented lesions. I do a lot of dermoscopy, and it's a lot of deciding whether something is benign or malignant, if something is melanocytic or not melanocytic, and coming up with the right diagnosis, deciding whether to do a biopsy or not. Whenever I do a biopsy, I always take a photo and I take a dermoscopy photo, and after I get the biopsy results back, I always go back to the photos. And I think that's a really important way that I continue to hone my skills because I then take the photos, and then I put them into PowerPoint file. This is my current system. I have a PowerPoint file for the year, which is arranged by diagnosis, and then I have a master PowerPoint files that have say all the basal cells, all the melanomas, et cetera, and then those turn into the lectures that I give. It's that kind of reiteration. Getting the diagnosis, looking back at the picture, figuring out what are the features that pointed to that diagnosis, and then also having to teach other people from those photos. That really hones my eye, I think, and continues to make me better and better, and that's what I always recommend when people are first learning dermoscopy, is take photos of whatever you biopsy and go back and look at the photos, and you will continually learn from that, and you will get better.
[00:05:08] Christine Ko: I love that. Doing that, putting it in PowerPoint, going back, the reiteration: it's deliberate practice. Earlier too, when we were talking about working with our children and working on responding over and over to unexpected events, all of that's deliberate practice. It's a way to get better, to focus on something and to have feedback. That's great.
[00:05:25] Do you have a diagnostic process in general?
[00:05:28] Jennifer Stein: When I do a skin exam, I'm very influenced by Jean Bolognia, who mentored me. From the Women's Derm Society. I got to spend a few weeks at Yale. Her process is, you always want to start with that low power view of the skin. You always want to look at the patient, take a step back, figure out what's normal for that patient, what's their signature nevus, and that's then gonna help you figure out what's not normal. What is the ugly duckling, the thing that stands out? So always go from that lower power then to the high power. That's when you take out your dermatoscope. And you look at something. And either it snaps right away and you know what it is. And that's your answer. Or sometimes you're in that in between phase where maybe the lesion is giving you a mixed message. Whenever I'm not sure, that's when we do the biopsy.
[00:06:13] Christine Ko: How do you minimize diagnostic error?
[00:06:16] Jennifer Stein: This is a good question. You can only know the right answer, you only know the gold standard after you've done the biopsy, so if you've biopsied something, you can say, were you right? Or were you wrong? But, you never know the answer for something that you didn't biopsy in the first place. The closest we can get to that is if you have continuous relationships with patients, and they keep coming back, and they're not developing thick melanomas. I think that's an indirect sign that you're doing okay. It's really important to have a good relationship with the patient, where you tell them, I think this is okay, but if anything changes, let me know.
[00:06:51] Christine Ko: Great answer. Jerome Groopman put it in his book, called How Doctors Think, that, really, the patient is our partner. The patient is another sentient, thinking human being in the room, always. Having a good relationship with the patient saves me from error. Absolutely.
[00:07:11] Jennifer Stein: That is so true because when I'm looking at a lesion, I'm also looking at the patient's face. This is why I prefer to do something in person, live, while I'm talking to a patient, over a store and forward telemedicine situation. Because when I look at something, most of the time you look at it and you just know right away, it's good, it's bad, it's clear. Your confidence shows on your face, and you reassure the patient. Or it's clear that you need to do a biopsy. But for those indeterminate lesions, I'm then looking at the patient, and I tell them, look, I'm really on the fence. Tell me more about this. Have you ever noticed it? And that's when I really start eliciting history from the patient.
[00:07:46] And in that process, I can also tell how worried the patient is about it. So that is a huge factor in my decision, whether to biopsy or not. If the patient is starting to get really nervous or the patient came to me because they're really worried. Then that's gonna shift more in the direction of doing the biopsy, for several reasons. One, the patient has to sleep at night. So if they're really worried, it's not that big in the deal in the end to do a biopsy. Two, I do think the patient's feeling about it, they're living with it, they've seen it every day, that matters, too. Patients have a sixth sense about these things.
[00:08:19] If the patient says they're really worried, you take it off. Sometimes the patients will tell you, that last melanoma, I knew it was melanoma, and everybody would tell me it was okay, but I insisted they biopsy it. And I think that is an important lesson. When they tell you they're really worried about something, that is a good reason to do the biopsy.
[00:08:38] Christine Ko: Yeah, I do trust the patient. Every once in a while, maybe about 1% of the time, I am surprised, and I'm really happy that I listened to the patient and did the biopsy.
[00:08:47] What is one or more lessons that you wish you had learned earlier?
[00:08:51] Jennifer Stein: When I feel like I'm in a rush, or I'm starting to get behind, that's actually the time to stay the calmest. The calmer that I can stay during an appointment that's feeling like it's getting a little bit out of control, the easier it is to bring that appointment, to bring that experience, back in control. In a way that will make the patient feel more confident and comfortable and allow me to take better care of that patient and to keep moving things along. In the end, It's actually more efficient to really just sit down, take a deep breath, let the patient talk for a while, look at the patient, and then there will be a way to bring that visit back around and back on track.
[00:09:40] Christine Ko: Yes. I try not to overbook, but just sometimes patient comes late and then another one comes early, and then somehow there's three or four patients waiting for me and I get anxious. I like that you said, just take a deep breath, stay calm. I recently learned a technique that I think helps me to do that. It's called the physiologic sigh, where you actually inhale twice and then exhale. That's been shown to physiologically decrease your heart rate.
[00:10:04] Do you have any final thoughts?
[00:10:06] Jennifer Stein: I would just say thank you so much for having me on, and I think what you're doing is so incredibly important because as physicians, it's important for us to be able to make the right diagnosis, and part of that is about practice and continuous improvement, but also a lot of what we do is about emotional intelligence, about taking care of ourselves, and enabling us to take even better care of our patients and to listen to our patients. Putting all of that together is really what's gonna allow us to continue, long-term, to take good care of our patients, and to be well.
[00:10:44] Christine Ko: I used to think that doctors aren't really human; at least, when we are being a doctor, that we are not supposed to be human. That's what I'm trying to fight against. And so I get to talk to people I highly respect like you and hear how you think about these things that I've been struggling with. So it's a real pleasure.
[00:11:07] Jennifer Stein: Thank you so much. I've learned so much from listening to your podcast. It's really an honor to be here.
[00:11:12] Christine Ko: Thank you.