I love Dr. Heymann's concept of a red file and a sunshine file - listen in to hear how the red file relates to deliberate practice! I also appreciate how he recites the Maimonedes prayer about every 3 months, and his insight into growing emotional intelligence over a lifetime. Dr. Warren R. Heymann, MD is Head of the Division of Dermatology as well as a Professor of Dermatology and of Pediatrics at Cooper Medical School of Rowan University where he was named a Master Educator in 2015. He attended Albert Einstein College of Medicine, did his internship at Bellevue-NYU Medical Center and his residency in dermatology at Albert Einstein Medical Center in Philadelphia, PA. He completed a dermatopathology fellowship at the Hospital of the University of Pennsylvania where he remains a Clinical Professor of Dermatology at the Perelman School of Medicine. He is the editor of DermWorld Insights and Inquiries, co-Editor of the textbook Treatment of Skin Diseases, and serves as a Director of the American Board of Dermatology. He is a past editor of Dialogues in Dermatology and has a column on “A Clinician’s Perspective” in the Journal of the American Academy of Dermatology. He received the inaugural Practitioner of the Year Award from the Philadelphia Dermatological Society in 2011. He has also received the Lifetime Achievement Award in 2018 from the Medical Dermatology Society and the Thomas G. Pearson Memorial Education Achievement Award from the American Academy of Dermatology in 2019.
I love Dr. Heymann's concept of a red file and a sunshine file - listen in to hear how the red file relates to deliberate practice! I also appreciate how he recites the Maimonedes prayer about every 3 months, and his insight into growing emotional intelligence over a lifetime. Dr. Warren R. Heymann, MD is Head of the Division of Dermatology as well as a Professor of Dermatology and of Pediatrics at Cooper Medical School of Rowan University where he was named a Master Educator in 2015. He attended Albert Einstein College of Medicine, did his internship at Bellevue-NYU Medical Center and his residency in dermatology at Albert Einstein Medical Center in Philadelphia, PA. He completed a dermatopathology fellowship at the Hospital of the University of Pennsylvania where he remains a Clinical Professor of Dermatology at the Perelman School of Medicine. He is the editor of DermWorld Insights and Inquiries, co-Editor of the textbook Treatment of Skin Diseases, and serves as a Director of the American Board of Dermatology. He is a past editor of Dialogues in Dermatology and has a column on “A Clinician’s Perspective” in the Journal of the American Academy of Dermatology. He received the inaugural Practitioner of the Year Award from the Philadelphia Dermatological Society in 2011. He has also received the Lifetime Achievement Award in 2018 from the Medical Dermatology Society and the Thomas G. Pearson Memorial Education Achievement Award from the American Academy of Dermatology in 2019.
[00:00:00] Christine Ko: Welcome back to SEE HEAR FEEL. Today, I'm with Dr. Warren Heymann, and I actually have the good fortune to be with him in person because he came to give several lectures to my Department of Dermatology here at Yale University, Dr. Warren Heymann is Head of the Division of Dermatology, as well as a Professor of Dermatology and of Pediatrics at Cooper Medical School of Rowan University, where he was named a Master Educator in 2015. He attended Albert Einstein College of Medicine, did his internship at Bellevue, NYU Medical Center, and his residency in dermatology at Albert Einstein Medical Center in Philadelphia, Pennsylvania. He completed a dermatopathology fellowship at the Hospital of the University of Pennsylvania, where he remains a Clinical Professor of Dermatology at the Perelman School of Medicine. He is the Editor of Derm World Insights and Inquiries, co-editor of the textbook, Treatment of Skin Disease, and serves as a director of the American Board of Dermatology. He is a past editor of Dialogues in Dermatology, and that's actually how I first, sort of, met Dr.. Heymann, by listening to his dialogues. He has a column on a clinician's perspective in the Journal of the American Academy of Dermatology. He received the inaugural Practitioner of the Year award from the Philadelphia Dermatologic Society in 2011. He has also received a lifetime achievement award in 2018 from the Medical Dermatology Society and the Thomas G. Pearson Memorial Education Achievement Award from the American Academy of Dermatology in 2019. Welcome to Dr. Heymann.
[00:01:33] Warren Heymann: Thank you, Christine. It's a pleasure to be here.
[00:01:35] Christine Ko: Welcome. First off, I'll just share an anecdote that I first heard your voice, really, in Dialogues in Dermatology, when I was a resident and Dialogues in Dermatology was still actually on CDs. I would listen to them in my car, and I very much enjoyed them. Thank you for that.
[00:01:52] Warren Heymann: Thank you. Yeah, it was a wonderful experience to do that.
[00:01:55] Christine Ko: Dr. Heymann gave a lecture of " 40 years in the wilderness: Lessons learned". The first lesson he gave was to be honest with yourself. He had several questions. What inspires you? What worries you? What do you love? What can you forego? Why are you here? What do you wanna achieve? I was just hoping that he could talk to us all about those things.
[00:02:18] Warren Heymann: It's important for each and every one of us. In a utopian world, we could do whatever we want whenever we wanted to do it. And I'm not at all implying that we can eschew responsibilities or have the perfect job. You have to analyze why, what is dragging you down? In practice, in 2023, there are many things that can drag us down. We all have to see too many patients too quickly. We all have to deal with prior authorizations and people looking over our shoulders and questioning what we do. We all look at competition from people who don't have anywhere near the training that we have. The problems are limitless, and it's easy to get frustrated. It's easy to look at this and say, what am I doing this for? The hardest conversation to have in this matter is a conversation with yourself. Why did you go through all this training to do what you're doing? Why did you really do it? You just need to be honest with yourself as to what's most important to you, what frustrates you. And then see if you can restructure your life in such a way that you can help foster those goals.
[00:03:34] Christine Ko: Yeah. I just wanna ask you two questions related to that. What's most important to you and how can someone figure that out if they don't really know?
[00:03:45] Warren Heymann: Well, I have a lot of gray hairs on my head. Just accept the fact that you may not know. Maybe you don't wanna be a physician at all, but your parents are pushing you in that direction. How do you know? More with time, more with experience. With time, you'll learn what you don't like to do. The irony of life is I never wanted to be in the operating room cause I really couldn't stand wearing masks, and here I am wearing a mask every day. Maybe I should have been a surgeon. Reasons and circumstances can change. Knowing yourself comes with time and with introspection, and you shouldn't ignore those things. It's important to listen to others, but it's ultimately the most important to listen to yourself.
[00:04:23] Christine Ko: Yeah. I did always wanna be a doctor. You and I are the same because you shared in your lecture, and you had told me this before, that you had meant to go into internal medicine. I thought I was gonna be an internist and go into internal medicine, but also more because I had read about Elizabeth Blackwell when I was very young, and that's why I wanted to be a doctor. She was like a generalist. And so that's what I thought I was gonna do. So I didn't even imagine I was gonna do dermatology. One of the reasons that I'm doing this podcast is I think that sometimes the system, like the application system or your family system or whatever, forces you into a certain path and it can be hard to tease out what's really my true feeling and desire or passion.
[00:05:07] Warren Heymann: Understood. It was a different world when I applied. It was very last minute. I did a dermatology elective in February of my fourth year. The match was the month later. [Yeah.] And I just said oh, stop the music. It hit me for the first time. I was a good medical student, but I wasn't great. And I liked medicine, but I wasn't super passionate about it. I knew what I didn't like. I'm not a particularly skilled surgeon. Psychiatry, I found interesting, but I knew I couldn't do it. I felt badly for them. When I did a dermatology elective, it was within a couple of days, and maybe cause it was I was with Dr. Michael Fisher and all the residents, and I just felt like, my God. I realized that I could learn these skills and do them. I felt, you know what? If I can learn what psoriasis looks like, it's gonna look like it in 50 years, and you don't have to do a test. And I said, this allows for career longevity. And I felt like if I learn this, I could actually do this over the course of a of a lifetime. So there were lots of reasons.
[00:06:11] And if you took the same circumstance today, I probably wouldn't have said, gee, I'm gonna take a year off and do a gap year and start over. I just probably would've done internal medicine and find a subspecialty like rheumatology that I enjoy, and I would've had a great career. People put too much pressure on themselves that this is the only thing to do. When you meet these students, it's dermatology or else. And I find that very disconcerting because that means to me that maybe you didn't want to be a physician in the first place. Dermatologists are physicians first. And then specialize in this. And if you feel like you need to just do this, then I'm not sure what type of dermatologist you're even gonna be.
[00:06:52] Christine Ko: That makes a lot of sense. One of the topics that I cover on this podcast is emotional intelligence. I really had zero emotional intelligence before I started thinking about the concept and hearing about it. Have you thought about the concept?
[00:07:07] Warren Heymann: Again, I'm not a psychiatrist or a psychologist. I understand what emotional intelligence is as opposed to an intelligence quotient. I think you'll learn this as you get older. You need to, when you're young and focused appropriately, so you're focused on yourself to get your footing. You have to be. But as you get older, you realize we're mortal. We're here for a short time. I'm not trying to be morbid. Every career has a life cycle. You train, you do, and you move on. And the older you get, you realize what Jackie Robinson said, the life matters for how it affects other people. What we do directly affects other people. And that's the other person, whether it's your student, your patient, your colleague, is of paramount importance. Not that you're not, you've gotta function well, you've gotta be balanced. You've gotta feel good, you've gotta take care of yourself, and it takes time to learn that you're part of a community.
[00:08:05] It's not all about you, it's about everyone. And I think it takes time to learn that.
[00:08:10] Christine Ko: No one's ever quite put it that way, but I really love that because I think for me it has taken time, and it will take time. The way that you phrase that just now, gives me and anyone else for whom it takes time so much grace. I do think the earlier that you learn this stuff, like for my children, they've been learning this emotional intelligence as part of social and emotional learning from when they were in kindergarten. They're still in the way that you were just touching on. You have to be, they need to be involved with what 15 year olds and 12 year olds are concerned about. Teenagers are supposed to be self-centered. That's part of puberty and growing up, and yeah I think that's really true. I never really conceptualized it that way, that I think part of emotional intelligence is going through life and getting to a certain age and a certain stage.
[00:09:02] Warren Heymann: It's interesting as you get older, life is almost like a bell shaped curve. You start out in diapers. We often end up in diapers. We get to the point of emotional intelligence, and then things happen and you retire and your circle gets smaller. I'm not saying you're withdrawn, but you start getting medical problems and you have to refocus on yourself again. There are exceptions to the rule on everything, but I think that's the way it works.
[00:09:27] Christine Ko: Yeah. In Warren's great lecture on his 40 years in the wilderness, and the 40 refers to he's been practicing for 40 years in dermatology and dermatopathology, in medicine, as a physician. Two of the other things that he said that I have to reflect on more, but really I think will have a big impact on me is 1) he talked about the Maimonides prayer, and that he re -reads it and re -recites it when he comes back from vacation about every three months.
[00:10:02] Warren Heymann: I have to take a break every three months. Or I won't be fulfilling the oath.
[00:10:05] Christine Ko: Could you just talk a little bit about that? Cause I found that very interesting and insightful into yourself. It helps me as well, so I think it'll help other people. And the other thing is your concept of having a red folder and a sunshine folder, if you could talk about those two things.
[00:10:20] Warren Heymann: Okay, sure. Most physicians take the Hippocratic oath almost from day one. I went to Albert Einstein College of Medicine in New York and that was part of Yeshiva University at the time. We recited Maimonedes prayer for the physician. Your listeners could read at your leisure, but essentially it's talking about seeing the person in front of you as they are, understanding that learning is boundless, and making a prayer to do no harm, and to strive to learn and be in the right spirit. That's essentially it in a nutshell. Far more eloquent if you read it. That's an important lesson. We talked about all the trials and tribulations of practice, how it can gnaw at you. It's hard, it's draining, it's difficult to approach it the right way. You do need to be of good health, mind and body and spirit to do it. And that gets sapped with time. When I come back from vacation, when I haven't been thinking about it, when I've been trying to refresh. When I get back, I have to get back and be in peak form. And be in peak spirit. Basically it's saying a prayer that I can live up to that standard. Do I live up to that standard? No. Cause I'm human. It's an ideal. In this world, this very cynical world, people don't necessarily look at ideals because they think they're not achievable, and they may not be achievable. But that doesn't excuse you from trying to live up to the ideal.
[00:11:46] Christine Ko: Yeah, I love that.
[00:11:47] Warren Heymann: That's my ideal, and that's what I strive to do. Knowing full well, I don't, and I can't, but I don't accept that as an excuse. Cause I try. When I feel like not trying anymore, that's when I know it's time to step away and take a vacation, and I can feel it like clockwork. After about 12 weeks, I need a week off. I'm sorry, I forgot your next question.
[00:12:08] Christine Ko: The red folder and...
[00:12:09] Warren Heymann: There's a red file and a sunshine file. Let's talk about the sunshine file and get back to the red file, because yes, bad things will happen, but hopefully they're intermittent.
[00:12:20] And in the course of your day, you've done a lot of good things for a lot of people. And even though it's a fast-paced world and people sometimes don't say thank you, periodically you're going to get a nice note from a patient. You may get a gift, you may get an email. You may get a nice five star review on Google to thank you for what you've done and how you've helped.
[00:12:44] Remember those because for every one of the bad ones, there are dozens and dozens of the good ones. If you are like me or I imagine like others, you forget about that. [Yeah.] And you concentrate on the bad ones. There's truth to the fact that 1% of your patients lead to 99% of your problems, and you have to put it in perspective and remember that.
[00:13:05] [Yeah.] The red file is based on our 16th President Abraham Lincoln, who had a history of depression. It was called melancholy at the time, and his self-analysis. He was his own psychiatrist after the stresses, and I cannot imagine the stress of being commander in chief of a civil war, which puts our problems in perspective. But he would sit down and write a letter directed to whoever was involved in that problem. Not to send the letter, to write the letter. It was analysis, what happened? Why did it happen? Was he at fault? Was he not at fault? What did he learn? What could he do better? Really, a little morbidity and mortality letter.
[00:13:50] No matter who you are, no matter how talented you are, no matter how dedicated you are, no matter how brilliant you are, if you're seeing patients, life doesn't always go as planned. There are bad outcomes. That could be annoyingly bad outcomes, like patients just angry that they waited too long and stormed out the office, or the worst case scenario, which is death because of errors that you've made as a dermatopathologist.
[00:14:16] You didn't get the deeper section where the melanoma was. As a clinician, you happen to prescribe minocycline for acne, and that person developed myocarditis and died three weeks later. Bad things happen sometimes because of error. Sometimes you've done everything right and bad things happen, but we still have to deal with that emotional difficulty.
[00:14:37] I'm not even talking about the threat of lawsuits. That's a whole other thing. I'm just talking about when bad things happen to your patient. How could you not feel a sense of responsibility even when you've done things right?
[00:14:48] I think it's a mistake when bad outcomes come to just sweep it under the rug. I'm not talking about the legal sense now. I'm talking about your own reaction and oh, pardon me. S happens. [Yeah.] And it does and that's fine. You have to preserve your ego. But then what did you really learn?
[00:15:03] What could you do differently? I'm not saying to be self flagellating. Or kick yourself. [Yeah.] But to analyze, why did what happened happen? Is there something to be learned here to prevent it from happening again? And I think that's how you grow.
[00:15:18] Christine Ko: Yeah. I love it. Do you have any final thoughts?
[00:15:21] Warren Heymann: Yes, I am so happy I'm here with you today because when I've read your work, and work with you, I just know that the future of medicine is wonderful. So thank you.
[00:15:33] Christine Ko: Thank you very much.