Challenging patient scenarios

By Emily Margosian, Assistant Editor, January 1, 2023

DermWorld talks to Melissa Mauskar, MD, FAAD, associate professor of dermatology and obstetrics and gynecology at UT Southwestern Medical Center, about how to approach difficult conversations with patients.

DermWorld: Tell us about your practice.

DermWorld: Could you give some examples of a difficult patient situation?

Dr. Mauskar: Some are patients who have longstanding itch that causes them to be depressed. A lot of these patients will lose sleep at night due to their scratching, which can also negatively impact mental health. They are often anxious because they have been to many different doctors but have been told different things. One patient told me that it was actually easier when she got her diagnosis of breast cancer because she was able to talk about that with her friends, as opposed to when she was having pain in her vulva, which she was embarrassed to bring up with her partner or family.

DermWorld: Do you have any advice to help dermatologists approach conversations with patients about potential mental health concerns?

Dr. Mauskar: Often, we’re busy in the office and worried that there may not be a lot of time to address these concerns. More than just what my patients say, often I look to their body language for clues that there may be something else going on. A couple of years ago, there was an article in JAMA Dermatology that talked about the PHQ-2 screening test in dermatology. It’s really easy; it’s just two questions. The first is: “Do you have a lack of desire for things that you normally would do?” The second question is: “Do you feel more depressed or down lately?” If patients screen positive for those two questions, it’s important to dive a little bit deeper and spend a little bit more time with them.

Dermatologists may think this is something that patients are talking about with their primary care doctor or other people, but a lot of times these patients are coming to their dermatologist three or four times a year and may have much deeper relationships with their dermatologist than they do with their family medicine doctor. I try to impart that knowledge to the residents I work with — patients see us as a primary part of their health care, and we can make a big difference in their lives.

DermWorld: If a patient does indicate that they are struggling with their mental health, what would next steps entail?

Dr. Mauskar: There are multiple ways of approaching these kinds of situations. When a patient lets me know that they’re depressed or express that they don’t want to live anymore because of some of the medical issues they’re having, I think listening is one of the most important things you can do. I also try to direct them toward resources. There are lot of good mindfulness apps that have come out during the pandemic. I also talk to patients about counseling options, either online or through referrals. I see a lot of patients who are having pain with sex, so I have a name of a sex counselor I give to them so they can talk about the impact their itching or genital condition is having on their relationship with someone who is trained in that area. Many of my patients have anxiety and are frustrated with the effects that these conditions have on their quality of life. I often prescribe medications for my patients, but I also try to connect them with a counselor if they do not have one. Sometimes patients aren’t ready to start taking medication for depression or anxiety, but I think planting the seed that they have options can be helpful.

DermWorld: What advice do you have about interview technique when taking a sexual history?

Dr. Mauskar: It’s one area where patients can really tell when you’re comfortable asking these questions, and obviously the more you ask them, the more comfortable you become. When taking a sexual history, I think many of us just think about traditional penetrative sex, but asking about oral sex, and other ways that patients are intimate can be important. In general, asking direct questions is important, because often the patient feels less comfortable when we dance around the subject. Also, remember that sexual products like lubricants or washes can cause irritant or allergic contact dermatitis. I’ve often made the analogy that asking a patient with genital itching about the lubricants they use during sex is kind of like asking a patient with hand dermatitis how often they wash their hands. These conversations take practice, and if it’s been a while since you’ve taken a sexual history, it can be a little bit nerve wracking. However, the more you do it and the more you normalize these conversations, the easier they become.

I also utilize a questionnaire that patients fill out before coming to my appointments. This allows them to answer these questions at home and helps me dive right into many of their answers. I think using questionnaires can be incredibly helpful to address some of these topics that may take more time during the appointment. Patients really do want to share this information with their doctors, but they’re nervous to bring it up, so it’s important that we be comfortable and prepared to ask those questions when appropriate.

DermWorld: You’ve spoken before about intimate partner violence, and the possibility that a dermatologist might see evidence of physical injuries on a patient. How would you approach a conversation with a patient in that scenario?

Dr. Mauskar: It can be very challenging. Although I probably have these conversations more than most dermatologists, even for me it’s still hard to talk about. Men can of course experience intimate partner violence too, but roughly one in three women will experience some form in their lifetime. With intimate partner violence we tend to think about physical or sexual abuse, but there’s also emotional and financial abuse as well. During the pandemic, a lot more people experienced emotional abuse through their partners due to increased proximity or the loss of a job that was being taken out on a family member.

However, I think the most obvious signs for dermatologists are physical or sexual abuse, because when you’re doing a skin exam, you may see evidence of these issues. Personally, if I notice something unusual, I may say to the patient, “It looks like you have a couple different bruises here. What happened? How did you get those?” Again, I believe asking direct questions is important for this kind of thing. More than physical abuse, I’ve had a lot of patients open up about emotional abuse to me. They say that it takes someone multiple times being asked about a situation for them to admit that something’s going on or to ask for help. I think the more times people are given the opportunity to voice what may be happening in their life, the better for patients.

DermWorld: If a patient does disclose that they’re experiencing intimate partner violence or abuse, what should a dermatologist do next? Do they have any reporting requirements?

Dr. Mauskar: If a patient discloses something to you, I think the most important thing is just to listen to them and give them time. I know this is simple, but our body language can be very supportive. If you are standing, pull up a chair, move close to the patient and don’t be afraid to hand them a tissue if they start to cry. It is ok to step out of the room and collect your thoughts. If you think a conversation may take a little more time than you were anticipating, inform your office staff. If possible, let the patient have a bit more time in the room.

I’ll then pull up resources on the computer that can help while in the room. We have a service here to put them in touch with a counselor, but every state and community will have different resources for patients. I also have a relationship with a local women’s shelter and have flyers that I hand out to patients with a number they can call to connect immediately with a counselor. In one instance, I helped the patient dial a domestic violence hotline in the exam room and sat with her until we got in touch with the counselor. I stepped out and let her talk to them and just told her to crack the door when she was done. Helping them come up with a safety plan can be helpful. You can also put fliers in the bathroom because even if the partner is accompanying them to an appointment, they probably aren’t bringing them in the bathroom with them.

You’re only required to report to the police if a patient discloses or you suspect elder or child abuse, although different states may have different requirements. My advice to fellow dermatologists is that it’s helpful to have an awareness of what resources are available in your community or if there are any local hotlines that you can give out if you have a patient in this situation. As dermatologists, we develop close relationships with our patients. I don’t think we always appreciate the impact we can have on patients, and what they may tell us if we just dig a little deeper and ask.

Melissa Mauskar, MD, FAAD, is an associate professor of dermatology and obstetrics and gynecology at UT Southwestern Medical Center.

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