Rash Decisions, Life-Saving Diagnoses: Medical Dermatology with Dr. Marchand

And so it's a whole Dateline episode. And that was.

I did not see that coming.

No, no, Yeah, I heard it's never.

Good if you know somebody who was on a Dateline episode.

It's never good. It's never good. And if my kids and I are, like, in sketchy areas, I'll be like, I hear Keith Morrison's voice. This is going to be a Dateline episode. We need to get out of here.

Hi, everybody, and welcome to the podcast. This is Generations md. My name is Stephanie, and I'm joined here by my colleague Diana, Dr. Sarah Davis, who's also my mother. And today we have a very special guest, Dr. Marshawn.

Dr. Marshawn is a board certified dermatologist and the owner of a private practice here in Dallas called Rash Decisions, which is just like, such a cute name. So welcome, Dr. Marshawn.

Thank you. Thank you for having me. This really is an honor. Your podcast is amazing.

Well, we're so excited to have you here and just talk to you more and hear about your journey towards dermatology. And I'd love to get into some derm topics eventually, but just kind of going way back when was the first time that you thought about being a doctor?

So, gosh, we. I get that question a lot, honestly. I was almost born into it because my dad was an ear, nose and throat doctor. I was born in Beaumont, Texas, and my dad was really, really busy doctor. And I think generationally, when we look back, that would have been in the 70s. And as a private practice ENT, there were so few regulations then. My dad just really worked hard and it was the financial benefits of that were untold, especially in a small town. And he was one of very few ents. And so I never saw my dad. He was like never around fast forward. My parents were divorced and my mom moved me and my siblings to New Orleans. So I grew up in New Orleans and, you know, not being around my dad and he really kind of drifted away. We were. He was not a part of our childhood to much of an extent. Well, my mom was diagnosed with bilateral inflammatory breast cancer when I was really young. And I. I don't have all the, the formal, you know, dates and, and ages and all that, but I think I was like six. And she. This is very interesting. She had been. We still have the document for it. Admitted as an infant to Hotel Du Hospital in New Orleans for thymic irradiation. So this used to be a thing, and I don't know if it was a regional trend in medicine. But there was a phase in. She was 1944, and she, I guess, had a palpable thymus. And it was thought then that that might foretell a risk for childhood leukemia. And so she underwent this prophylactic thymic irradiation. Fast forward 30 years. In her 30s, she got bilateral breast cancer. And so most of my childhood was my mom's brave fight against that. In fact, it's funny that I've ended up in Dallas because one of the things that extended her life was an experimental protocol by a doctor in Arlington named Dr. Blumenshine. His first name, George. George Blumenshine. And then a final little side note, I am a big fan of Dateline, and I was reading about old Dateline episodes to see if I wanted to watch any of them. And one of them was about Dr. George Blumenshine because he had a romance with one of his office staff, and this drove his formal girlfriend, who was another oncologist, to kill him. And so Dateline episode. And that was.

I did not see that coming.

No, no.

Yeah, I heard it's never good if you know somebody who was on a Dateline episode.

It's never good. And if my kids and I are, like, in sketchy areas, I'll be like, I hear Keith Morrison's voice. This is going to be a Dateline episode. We need to get out of here. But anyway, so Dr. Blumenshine extended my mom's life by many, many years, but got dropped off from carpool at Baptist Hospital most afternoons after school because my mom was, like, on some drip or another fighting for a life. And so I grew up in a hospital environment because of that. And then when she was able to be home, she had round the clock care. And so I just kind of assumed, like, I never really saw myself in any other really different atmosphere than being a doctor. And then I. In the back of my mind, I knew my dad's a doctor, too. I mean, I'm, like, destined to go to medical school. And. And so she finally passed away when I was 14. And then I always kind of likened myself to Harry Potter because I sort of look like him and because he went to live with the Dursleys. Did y' all read the Harry Potter series?

Oh, yes.

Yeah. Okay. So he had to go live with the Dursleys after his covered under the stairs. Under the stairs. And that was my life after my mom died because I had to go live with relatives. And they. They only took me in because they had no choice. And it was really hard on them, and it was really hard on me. So when I was 17, I moved out. I was on my own. And so I graduated high school and I went to college. And I decided the best thing I could do is had a lot to AP credit. The best thing I can do is try to finish college quickly. So I did that. I finished a year early. And that, I think, was a real leg up for getting into med school. I think that just kind of being as independent a person as I was, and I'd done a lot of volunteer work, and I don't know, but it got me in. And it got me in right where I wanted to go. I wanted to go to LSU Medical School. People in my area of Louisiana, either they want to go to Tulane or LSU Medical School. Most of us think we're not going to get into the Texas system. It's too competitive. You know, unless you really have an Ivy League pedigree, you're probably not going to go up to the Northeast. So for me, I was just going to be happy if I got into lsu and I didn't want to go to Tulane because it was just. It had a reputation for just sort of being, like, more boutique, you know, and kind of like, not as legit as, like, a hardcore gritty medical school environment. And I got into both, and I went to lsu. So, so excited. But I went to medical school thinking I was either going to do, no surprise, oncology or ent. And I liked ENT a lot better. So I did all the rotations. I mean, I got pretty far down the road. And then a weird thing happened. In our third year of medical school, one of the requirements at LSU that's unique is one semester you have to do a derm rotation. People really bristle at it because the rotation's demanding, and you're expected to learn a lot of the dermatology terminology, which, as you know, is really, really unchartered territory for lots of medical professionals. We basically just, like, speak Latin all the time and lots of acronyms and so forth. So nobody wanted to do this DER rotation. And so I accordingly, sort of dreaded it. But we would go to the derm clinic, and the time would just pass in an instant. It was so interesting. And when it came time to take the derm rotation test, I went to study for it, and I was like, I know all this stuff. Like, every time we'd have a patient with this, that or the other, I had already read extensively about it, so. So interesting. So my closest friend in medical school she was going into Durham and she said, you're ignoring, like you lost the forest for the trees. Why don't you do derm? And so from then on, it was just kind of a marriage made in heaven. I ended up getting a spot at LSU in dermatology. And then in fact, I interviewed for a derm residency up at UT Southwestern. I remember the interview Will, and the, oh, God, the department there is second to none. And so I was really excited to get that derm residency. Unfortunately, when I finished dermatology in New Orleans, this. And this goes to the generational shift. When I finished in 2003, cosmetic dermatology was really still just emerging, and Botox was still kind of new. The Carruthers had just introduced it from ophthalmology into the field of dermatology. Cosmetics, I think, really took off with Botox, but it was rapidly accelerated with laser. Laser came along and at the time I finished it, many dermatologists, but not most had a laser or maybe they had an ipl. And most had done some Botox and would probably be considering making it a mainstream part of their practice. But it all still was a novelty. And there was a lot of skepticism towards fillers because the main filler we used was bovine collagen. You had plenty of allergic reactions to it, so it was a little more stigmatized and it was considered like a little bit more of a out there treatment. And chemical peels were very much, very, very popular. And so at that time, most practices were still 90% medical dermatology. And in New Orleans there were tons of them. Therefore, it was exceedingly hard to get a job. And so I was granted a subsidy through the federal government to move to an area that's medically underserved in whatever specialty you're in. And so Beaumont, Texas, as I mention, my dad was in the picture at times and he mentioned that if you're having a struggle getting a job in New Orleans, you really ought to look at Beaumont, because we have only a few dermatologists and they're all booked way out and they get to do whatever they want. You could just stick with medical derma if that's what you want to do. You could segue into doing more surgical derm. The sky's the limit because the patients are really having a hard time getting their care needs met. And I was married at the time and my husband was a family practitioner, so we managed to get that subsidy. I don't know if it was a grant, full on grant. You didn't have to Pay any of it back as long as you practice in the area for five years. And you had to be on hospital staff and take, you did have to take lots of call, but in Durham the call is pretty minimal. And so for me the call was 99% inpatient call as opposed to ER call. And so I just saw lots and lots of inpatients. But I kind of enjoyed it. You don't really get paid for that, but it's just part of the, the service you provide because you went into practice with no debt. No debt. Every single part of your, your equipment, your staff, you have an income guarantee for a few years. And I don't know programs like that still exist. But that was our start in Beaumont and just life events happen. And I had two children and I got divorced. And with that in Jefferson county, you know, you, even though I had sole custody of my kids, I couldn't leave. They can stipulate, of course, that you, you're bound to a geographical area. So there I was in Beaumont and I just stayed on doing, practicing derm and the full overview of my derm path. But the, the very beginning of it was that test. When I went to study for that third year rotation test. It was like, you know, funsies. It was so easy and it just came naturally to me.

I have a question. Just, you know, dermatology now is, is very fashionable. All these people want to be dermatologists, which every time I talk to medical students and you know, I graduated from medical school in 1995 and I didn't know anybody who went into dermatology. We did not have a required rotation in it. Most of us didn't do a rotation. Like, you know, I just, I never remember anybody even talking about it or anything. And I'm curious if kind of as the cosmetic part of dermatology took off there in the early 2000s, did that really increase the popularity of dermatology?

I believe it did. I do. You know, you can still look at statistics today and the numbers claim that there aren't enough dermatologists. And I swear, I think, and I'm not one to really pick through data. I've published one article in my life. I'm not a big publishy type of gal, but I think that the data reflects that the real need is for more medical dermatology because it's understandable that a generation of people would want to go into a field in medicine that's going to be really relaxed in terms of rigor, yet extraordinarily high immediate reimbursement. So cosmetics, I mean, it's, it's, you know, crudely put. It's, it's a cash cow. And I do think that that's when the overall. That's such a good word. It's, it's glamorous. It to, to go into dermatology. They say going to a dermatology convention is like being at a fashion show. And it is. You really do see some very, very esthetically glammed up folks. But in my humble opinion, I don't think that's an asset to our field at all. And I can totally understand why maybe mid-90s and probably totally the case earlier than that, very few and very odd personalities would gravitate towards dermatology because it's so cerebral and it's, and it's a little bit thankless because admittedly a lot of what we force ourselves to learn and memorize, we never use leagues and leagues of information on rare processes that you're never going to see. Zebras galore.

Yeah, yeah. It doesn't include just putting a steroid cream on there.

No. You have to like enzymes, you have to check to put people on weird stuff and you know, old medicines with new uses and, and just all the genetic stuff. You know, it's, it's challenging just to keep up with it now. And I, I wonder, you know, I kind of find myself doing lots of cme, like way more than I need just because I enjoy it and because I. There seems like there's just so much to learn. And I wonder, the cosmetic dermatologist, do they do all this, like, do they know these medicines? I spoke to a friend of mine who graduated Tulane dermatology my same year, and she practices up in Washington D.C. and I asked her if she had seen a recent article. There was some gene therapy for what's called dystrophic epidermalysis bullosa. And I said, courtney, do you, do you know anybody using this? And she said, no, wait, tell me that disease again. And I said, you know, one of the ebs. And she's like, oh no, I don't even read about that stuff anymore. Like, so. So I think that it's really changed a lot. Yeah. Well, first of all, I just want.

To say thank you for sharing your story because that was really impactful and that was incredible. Can we kind of, going forward, can you kind of talk about the difference between medical dermatology and cosmetic dermatology?

For sure.

So medical dermatology is all the things you think of in terms of, you know eczema and itchy skin and reactions to poison ivy, psoriasis. People who are born with a genetic disease that involves some skin anomalies. So for example, you've heard of neurofibromatosis. This is, you know, covered with neurofibromas. And although it's very variable, the penetrance of neurofibromatosis is among the greatest variability of all processes that have variable penetrance. You can see somebody with like six neurofibromas and like nothing else, I have to have the criteria for NF on a, on a little note card that I reflect and make sure, okay, are they really meeting all the criteria? So that's medical dermatology, all that genoderm people who, I mean frankly acne and Accutane are still medical dermatology. So if you're managing something that's probably going to have some long term check ins needed, we're going to probably be doing a little bit of blood work and heredity of it is, is part of the story. I mean just all the usual things that would go with more traditional disease states. Cosmetic dermatology is purely relegated to all, you know, voluntary procedures. Things like Botox and fillers. Almost every laser procedure is cosmetic in nature. You know, I guess you could make the argument that some laser treatment of real bad scarring, laser treatment of some hemangiomas that ulcerate or are very symptomatic, those are medical necessity. But the vast majority of laser is cosmetic dermatology. And then you know, you have, I mean scads of other things, all these like tightening devices for body sculpting, all the way down to muscle stimulator things to tone, tone your six pack. I mean all of that now evidently falls under the umbrella of cosmetic dermatology.

Which is pretty funny. That's, yeah, seeing those things like, okay, it's like you're doing 1000 sit ups in an hour. Just put this machine on, sit in the room and it just does all the sit ups for you. How does that dermatology.

The Venn diagram gets a little more interesting there though because if you're going to kind of find a little bit of overlap between medical and cosmetic dermatology, you need to put a third circle in there, which is a whole bunch of other people who are not dermatology at all who are doing the exact same procedures as the cosmetic dermatologists. In fact, I've found that patients who come to see me while in Beaumont, some would ask me to do cosmetic derm for Them, almost all of them already had a dedicated person they preferred to go to for whatever the need was. So it's almost like, well, I go to this lady and she does my eyelashes, and then I have this med spa over here, and I like theirs because I just like the way they do my hair. Remove a laser, and then I go to Houston to get my filler, you know, so people shop around for cosmetic dermatology, which is why it's not really dermatology. It's just this whole field of, of, you know, elective aesthetics. And I, I, it's, It disappoints me that it's up such a big part of our field because it takes away from our real raison d', etre, our real reason for being, you know, and it then it makes people like me look like mega nerds, which is also, like, a little annoying, but I'll take it.

I went to this med spa because I had this gift certificate that somebody had given me. And so I went to get a facial, and then the whole intake form was basically like, what do you hate about yourself? What do you hate about your eyes? What do you hate about your lips? And blah, blah, and, you know, and, and draw this and that. I mean, it was like pages and pages, and I just kind of, like, put lines through it. And I'm like, I'm just here for a relaxing facial. Like, I'm really not here to say. To look in the mirror and criticize everything about my face. I mean, I kind of came out. I was like, I realize I don't look perfect, but I'm not trying. I'm not a model. I'm not trying to look perfect. So anyway, the whole thing, I just thought, God, there is something just very wrong with this whole scenario.

The psychology of it is the worst part. And it's. Patients will ask me, like, what do you think I need? And I'll say, if we took a picture of you for the before, and you just kind of made like, a, you know, dull grimace face, and you didn't have any light shining on you, and your hair was kind of messy, and then we took exactly. You brushed your hair, put you in good lighting and had you smile, people will think you had all kinds of stuff done. It's. It's so psychological. Another thing I found really interesting from a psychological realm is, and I see this around Dallas, I think big cities anywhere probably have the same thing happening. While we used to have to just cringe at the thought that anyone would have downtime, that they Might look red or be embarrassed if people knew they had work done. You know, now it is chic to go around with your face that you just had a vampire appeal the day before. You just had some laser done. It's a badge of honor.

Ah, that's. That's true. That. That's true. Here in Dallas, it's just, you know, everybody's always doing something.

Well, I mean, even just kind of, as I've noticed, I feel like it's gotten a lot younger. Like, even people my age getting Botox and filler. What do you think about that?

Oh, it's the Internet. I mean, you know, I. I know I sound just like everyone's grandmother, but we had it so much better without all that. The. The demands of the Internet intertwined with the psychological ramifications of the availability of the Internet, they've just sort of corrupted and warped everything. And so that's another one of the biggies, is shared information has led to basically shared body dysmorphic disorder. Because I think people's expectations based on, you know, social media posts and just so many things are faked too. It's distorted everybody's expectation and entitlement of, like, what they're supposed to look like. The age barrier we used to see where. I guess that was largely based on the legitimacy that, like, people who are old enough to have wrinkles would have. The stuff done. That age barrier is gone. It is gone. Yeah.

And I, And I know, you know, we can shift to talking more about the medical stuff and not the cosmetic stuff as much, but I am just curious about a couple things in regards to, like, like preventative Botox. A ton of people my age get Botox because they're like, well, if I get it now, then those muscles are gon stretch less, and then I'm gonna have less wrinkles in the future. What do you think about that?

Absolutely true. Preventative Botox is extremely effective. The fact is that if your collagen gets yanked on over and over in the same place with. With many, many years, you're gonna permanently injure your collagen and lose collagen. But, you know, the devil's advocate side of that is. Or my side of that is, oh, well, like, you know, as you age, you're gonna develop signs of that. I mean, you. But it is fully true as far as a medical, you know, explanation or whatever it's. That is true. Yeah.

The one other thing that I'm curious about is, again, like, people my age getting filler, and I see these images of I don't know exactly the imaging technique that they use, but essentially that the filler never leaves their face and it stays in there. Is that like, what are long term ramifications of constantly getting filler starting at a young age?

Well, remember to. Filler is not without risk. So back when I was, you know, coming out of residency and all these things were just really starting to get popular, there was an absolutely unbreakable rule that you would only use Botox above the eyes and you would only use filler below them. And really even farther down than that. I mean, you know, just your, your nasolabial folds and. And now of course, anything is used anywhere for any reason, for any combination of results. But as far as how long does filler stay in your face, the bigger question is how safe really is filler during the injection? A tiny, tiny, inadvertently embolized amount of filler will blind you if you get it in the wrong place. I mean, if you people get little tiny lines up here done, and they'll, they'll get their forehead lines filled and I mean, you know, you're, you know, anatomy, you embolize that artery, even the smallest bit of collagen is all it takes. Embolization of filler elsewhere can give you horrendous scars, just necrosis at full thickness with a gigantic scar. So that's the important thing I think people should not overlook. But in terms of long term, you know, the filler hanging around forever, I just think they're so distorting that they are space occupying materials. And you're necessarily going to kind of rearrange things when you put them in. Some fillers really do wear off after a length of time. If I was, if I was kidnapped and forced to have filler put in my face, I would beg to have a hyaluronic acid filler because at least there's hyaluronidase and it can dissolve it if you don't like your result or if the result is damaging to you.

Yeah.

Do you, I guess, kind of talking about these like adverse effects that you see in cosmetic dermatology. Do people ever then come into your office and you're seeing kind of these ramifications of these sort of things? Is that ever something that you see?

You know, that's a really good question and I have to give it to the cosmetic dermatologists. Say what you want about the necessity of having all these procedures and the, you know, morality behind it. Dermatologists are very good about seeing patients through when they do have a complication So I would say not too often because I'll see people who mention, oh my gosh, last year I got some Botox and my eyelid drooped for six months. It was miserable. And I'll say, well, you know what they do about it? They almost always say, oh, my gosh, my dermatologist was so great. She really held my hand through it. She gave me these eyedrops to use and it got a little bit better. And now I'm probably just not going to have that much Botox done on my forehead anymore. I feel like the dermatologist really do a good job of follow through on the complications.

That's important. I mean, nobody should be doing any procedure that they can't manage the complications of.

That's exactly right. You know, talk about advice. That's a huge piece of advice. Don't ever do anything you can't handle the complications from.

Yeah, that's. I mean, my mom, I feel like, ends up dealing with a lot of that. People come back to her and ask.

Her about issues of procedures.

Yeah, but how did you kind of find your niche in your specialty and kind of moving on in how you started this practice that you have now?

I think Beaumont shaped it a lot. So you'll remember when I was kind of explaining my journey. So we ended up in Beaumont and I was right out of residency. So immediately out of residency, I feel like you have this assumption that everything is expected of you. Like, I. Somebody could come in with like the worst blistering disorder ever and I would need to fix it. And so I didn't limit my practice at all. It was taking all ages, infants, you know, everything. And I discovered that one of my mentors used to say, just get good at the common things, you know. And I started to notice, like, gosh, all that esoterica that I thought I was going to have to be, you know, equally as good at. There are specialists for that. And so I went from the first few years, like referring no one out, handling everything myself. I was taken off basal cells by people's eyes and, you know, decent results. But over time I discovered that it made for happier patients, good referral relationships, and basically it allowed me to get good at the things I really was inclined to be good at. So I just, I think what patient flow you have and where you are in availability of referral options for really tricky stuff that, that shapes you. I often wonder the same thing about dermatologists who they segue often go into contact dermatitis. So I understand the ones that leave General derm and end up doing Mohs surgery. That makes sense. They're very procedurally inclined. They don't want to do cosmetics, and they. They don't mind the tedium of most surgery. Perfect sense. But the contact dermatitis people, I often wonder why they came into derma in the first place. Because contact dermatitis is basically like being a chemical engineer. I mean, you have to know so many complex interactions between substances. And so those folks, like, did they ever go into general practice first? It's not like there's a fellowship in contact dermatitis. You could sort of make one up for yourself by going to train with a renowned contact expert for a while. But those are the really cool people to talk to. How do they get involved in that? And they're not that many of them in the United States, and they are wizards, and they do.

I've never heard of that. That's.

Yes. Here in Dallas. One name that's really good to know is Karina Woodruff. And then at UT Southwestern, you have Dr. Ponciano Cruz. He patch tests. Cruz is a little bit more, you know, well rounded, I guess you could say, because he. He really does do like all the things. But he is a wizard at contact dermatitis and has a big patch testing lab. But Karina Woodruff is a solo practitioner. Well, I say that she's in a PE firm, but I think she offices alone and just has a contact dermatitis capability. And many people refer patients to her. I used to patch test back when I used to think I had to do it all. I used to use a really complicated set of patch tests called the North American series. And I found that I could figure out some people's allergies and had really good results. But sometimes patients would come and they'd have multiple relevant allergies, and it was sort of over my head how to wheeze it apart and really meaningfully change things for them. And so I started to refer out patch testing. You refine the kind of practice you have, I really think, based on what's available to you for referrals. Because dermatology is huge. There is so much they say it's one of the specialties that has the greatest number of individual diagnoses. It's like, I think over 3,500derm diagnoses.

Yeah, I mean, I think that that is so important. And I can imagine with that it can be hard to kind of find your niche and what you want to do. And I don't know, just thinking about that it kind of makes sense that a lot of people want to go down this cosmetic route, because when you have all of these paths in front of you and there's a big, shiny diamond in one path, then I feel like you kind of want to follow that.

Yes. Yes. Sometimes I do feel like I picked the pile of rocks, but they're a good pile of rocks. They're heavier. They don't shine as bright, but they're. They're my rocks, and I like them.

One thing just as, like, I know we're bouncing around a lot, but as you're kind of telling your story and just talking about your dad, who was so busy as an ent, did that not make you kind of, like, resent the field of medicine a little bit? I'm just kind of surprised. As you were saying that story, that. That. And obviously you had the experience with your mom and everything, but then it ended up leading you down a path towards medicine.

I think that's a really good question. I think that most of all, I just was in awe of how much they were able to do for my mom and having to be in the hospital so much over the course of my upbringing. Everyone was always really nice to me, and I just had so much respect for them. I knew they'd all studied really hard, and. And I just. I thought they were miracle workers, you know, And I thought, if there's any chance I could be one of those people, I. What more could my. More meaning could my life have than doing that? And as far as wanting to pick ent, I don't know why I would have gone into that, other than I really, really like kids, and I knew my dad worked a lot with children. Tonsils and tubes and adenoids and all that good stuff. In fact, there was a brief stint in medical school where I did my NICU rotation, and I loved that. Loved it. But Derm won out.

Yeah, I was thinking the same thing when you're talking about your mom and all that, particularly because, you know, it seemed like medicine kind of did her wrong if that, you know, if she had that irritation. Yeah. Yeah.

Interestingly, I did not find out about that. This is a cool story, and I don't know how useful it'll be for the podcast, but it's a very good story. Okay, so my mom died in 1988, and by the time Katrina came and she was a lifelong New Orleanian, except for the 10 years she was married to my dad and lived in Beaumont. And she was so pleased to go home to New Orleans, where she had these three young kids, and her parents were there, and I think she had a lot of family support, being a newly single mom and three kids and all that. All that. So, anyway, she moved back to New Orleans. Loved New Orleans. Absolutely passionate about Mardi Gras and many of the other traditions. The Mississippi River. She knew the French Quarter like the back of her hand and. And had been raised to really love the culture of the Deep south and more specifically, Louisiana. So when she died, one of the things that stayed very much alive to me was my love for New Orleans. And that's why it was really hard for me to discover at the end of residency, I wasn't going to be able to stay there to practice because it was just too much of a glut of dermatologists. And so when Katrina came, I had recently moved to Beaumont. So Katrina was in 2005. We had started the practice in Beaumont at the end of 03, beginning of 04. So Katrina's arrival put me at, like, a year and a half in Beaumont. It was really emotional for me to see precious New Orleans getting, you know, wiped off the map. And not too far after that, we got Rita in Beaumont, and we lost our office. But that's a whole nother story. Wow. Yeah. So with the aftermath of Katrina, as things finally began to kind of dry out, I received this notice in the mail, and it said, you've been discovered to be the next of kin to an individual in whose name a Hibernia bank lockbox that was damaged by Katrina has been removed to a remote site, and you are responsible for coming to claim the contents. Whoa. What. What on earth is this? And so I was in Beaumont, and we had lost our office, and it was, like, a really hectic time. I. You know, my son was a baby, but I took the drive to New Orleans, just kind of. I didn't know what to expect, but I figured maybe my mom had had this lockbox. And so I went to the Hibernia, and they give you directions to go to New Orleans east, and you go to this gigantic. I mean, it's a huge piece of land, and they got warehouses, and each warehouse has, like, one segment of the flooded lockbox because it was in. In what's called the Broadmoor in New Orleans. Absolutely. The bottom of the bowl. So much water. And so they had sprayed these lock boxes and tried to kill off pathogens and make it where, you know, we could inhabit the air around it and not breathe in all kinds of terrible stuff. But you had to wear A hazmat suit and mask and all that. And you would show your id, and they'd give you some decoded, like, coded numbers, and you'd go in, you put your hazmat on and give them numbers, and they'd walk you over to a table and bring you your box. So I sat at the box, and I opened it up, and all that was in the box was a Ziploc bag, but it had documents in it. And I was so perplexed. I thought, you know, was this one of my grandparents? This is so weird. And there weren't too many documents in it. Some of them were just old deposit certificates and banking information. But one of the things in there was the admission document for hotel do for my mom's thymic irradiation. And it was at that moment I was like, why on earth would she have saved this? It's like a. And as I'm reading it, I'm like, huh? Thymic irradiation, That's. So mom had that then. Look, she was only, like, you know, six weeks old or something. That's so weird. And then it clicked. So I did not know about her thymic irradiation until Katrina. So as far as the doctors doing wrong, my decision was made way before I knew about that.

Right. That ship had saved.

That is a wild story.

And I still have it. I threw away all the other papers, but I do still have the key to that lockbox and my mom's admission paper. Another thing that I just wanted to add as a footnote to how I could have gone through a situation like that yet still decided I want to go to med school. My mom loved her doctors. She loved them. At that time, doctors were, I think, a little bit more personally connected to patients. You know, kind of the house call type of guy. And he comes with his little doctor bag and comes to your house. And I think the doctor, his name was Charles Brown, he would come and check on my mom a lot, and she'd call him Charlie. I mean, they had this whole banter. I vaguely remember little snippets of how much she liked him. She got me a summer job in his office one year just because I was summer break and I didn't have anything to do, and I was like, what, 10 or something? And they let me work in the file room. So anyway, she loved her doctors, and I think that added to it. It added a whole other layer of admiration, you know?

Yeah, that makes that. That. That makes a lot of sense.

Yeah, that does make sense. But that is like A lovely to be able to, like, grow up and see that and be able to see that relationship. How do you feel like that's impacted, like, how you practice today?

Oh, tremendously, tremendously. Because that's the biggest reason that the practice I have now is the way it is. I want to be able to not have the insurance generated pressure to roll through people really, really quickly because you miss out on all the personal connections. And not only are those personal connections meaningful, both for the patient, for me, for the staff, but those connections often are a path to better care for them. Because when they know you better, they tell you more. When they tell you more, you can figure more things out on their beh. Tell you the number of times in casual conversation with patients, they'll make a comment and I'll say, wait, did you just say that you went to. And I'll say, that's why your folliculitis came back. It's because you got in another hot tub. Why didn't you tell me that? You know, so I feel like being able to really connect with people and they know that you get them, you listen, and you kind of validate them. I feel like my mom's doctors did that, and it was important to her, and it. It probably made all kinds of differences. I don't think Charles Brown would have sent her to Arlington to Dr. Blumenshine in the first place if he didn't have that kind of relationship with her. I mean, that's just, you know, me imagining things many, many years later, almost 40 years later. But in my practice, I feel like I haven't done a thorough enough job. If the patient doesn't feel like I really listened to all the stuff they told me.

Yeah, well, and if you don't have that connection, they're not going to do what you tell them to do either. You know, they'll. They'll just kind of leave. And I saw something about, like, how many prescriptions are thrown in the trash outside of an emergency room? You know, they're just like, I'm fine, I'm not doing that. And they just, you know, throw it out and leave. And so because they didn't make that whole connection and really understand, you know, why they need to do whatever they're saying, whatever they. They're being told to do.

Yeah, no, it's the thoroughly prescriptions that's so heartbreaking and so true. Another thing, in terms of the connection and compliance with what you're asking them to do, which, by the way, I think the euphemism for compliance. Dr. Davis, do you use the word compliance or do you use adherence? Adherence, evidently, is like that does.

That does sound a little kinder and gentler. I don't know. You know, I know.

Don't.

I don't have anybody to correct me because I'm in solo practice. So I probably use all kinds of words that I'm not supposed to be saying.

Whatever words you want to. Well, to amplify adherence, I like my. Especially my teenage patients, I like them to not be opposed to what a particular prescription cream is going to feel like. So I'll often leave the room, go and get a sample and bring it back and show them how to open the tube. And then I'll put it on. I'll make them put it on in the. In the office. And I don't think you can do that if you haven't been a good listener prior to that. They'd just be like, this whack job just reached out and started to, like, put cream all over my face, you know, But I do that a lot. And I swear it makes a difference because I think when you send them home and they know their mom's going to be getting a prescription filled and bring it home, and they know there might be side effects and all, it's very easy to let that tube just like, sit in the bathroom and not mess with it for a while. But if they've already used it in my office, they'll be like, oh, yeah, let me do it, like she did it. And I swear, I think that's helpful. Adherence. And you don't see the.

They don't see the price that they're paying, that their parents are paying for it.

Exactly.

Yeah. That's important.

Yeah.

Because there's just so much information out there TikTok and social media and stuff about what skincare to use and so much of that industry. Like, how do you deal with that when talking to patients?

I urge skepticism. And I'll show them examples of active ingredient lists where it's. They're all the same. They're all the same. This is true in almost every category of what you'd buy at the drugstore. This is true for all the different wart medicines. Just read them all. They're all just 40% salicylic acid. It's true for all the acne cleansers. You're going to get 2% salicylic acid no matter what. It's true for dandruff shampoos. You're gonna get, you know, X percent of selenium sulfide or, you know, zinc pyrithione or some ketoconazole. 1%. They're all the same. It's trial and error. Pick one you like the smell of. It's a good price. It's available at the place you usually shop. And just be skeptical of all these brand names on the Internet that you see people tiktoking about. Ask yourself, is there really anything better about that product, or is the better just gonna benefit the person who's gonna make it and profit off it because they kind of like, you know, tricked you or convinced you that theirs was something better? If it was that much better, don't you think I'd know about it? I'd be wanting you to use it. So I try to just really urge skepticism.

Is there any stuff that you mentioned earlier about just trying to keep up with the literature and everything? How are you able to do that? And have you seen shifts and, like, stuff coming out with skincare? I feel like it's changed a lot. How much of that is like actually research coming out of how things are affecting your skin differently and how much of that is kind of just this commercialization of all of it?

I'm gonna definitely sound like a grandparent when I say this, but almost all of it is commercialization. None of the basic science of skin has changed. I think the one difference was ceramides when. When ceramides were made so bioact bioavailable in various moisturizers and hyaluronic acid. Those two things meaningfully are better moisturizers than we used to have. So that. That there is truth to that. But they're ubiquitous now. Everything's got those in them. As far as all the TikTok stuff, I don't even really keep up with it. So the way I operate is I keep up with my journals and if anything comes along, and I think, well, now there, that looks like a good idea. I'll tell you, there's a brand in particular maybe you've seen on Instagram. Musely M U S E L Y Musely. I'm really impressed with this company because they not only make their ingredients very easy to find on the website and in. In pretty simple, like simplified layman's terms. Not only do they make that all available, but they're very, very good ingredients. So they'll put things, they'll put ingredients in, for example, a fading cream, a bleaching cream that I never would have thought to marry together. Somebody really clever is formulating Their stuff. So yeah, occasionally a product will come around that wasn't in my journals and I'll just, someone will mention it or I'll see it when I'm Instagram and I'll really think, okay, there's some legitimacy here and I'll tell patients about those. You know, that used to be how we viewed La Roche Posay. La Roche Posay was just this like just trying to cut in on the market, you know, and make people make the cetaphil buyers think that what they were buying was too much of a fuddy duddy product. They needed to spend up and get the more refined La Roche Posay. La Roche Posay has a very, very strong market position and lots of patients like the stuff. Their stuff's not better. In fact, I hate sunscreen. Their, their aunt Helios is one of my least favorite sunscreen because it's super runny and I feel like you sweat it right off. But the point is that companies will come along and some of them really will have staying power. And I think Musely is going to be one of those. But I just read my journals, I make sure nothing earth shatteringly new is coming out. And then I just kind of put my blinders on to all the tick tock crap. Patients will ask me like, what do you think of my drunk elephant? Blah blah, blah. And then I'll look up that product and I'll look at the actives in it, I'll look at, at some of the preservatives and so forth and give them warnings. You know, so many things have potential allergens in them. And so a popular one I see a ton of is tocopherol vitamin E topical. Vitamin E is so prone to generating allergy. So I hate it when people just like throw that in and it's not even inactive. Why do they do that? But same with propylene glycol. So as far as keeping up with the new stuff coming out, it isn't that hard because most of it is crap. Crap. Yeah.

My mom had a terrible reaction to vitamin E and she was in the sunscreen and she was. Because she was using a kid's sunscreen because it was around. And the only difference between that and the regular one was it had vitamin E in it for some reason. And she's like, I can't use the kid stuff. It has this terrible reaction. But anyway, like why would they put that in there? It's a kid sunscreen.

It beats me.

I was gonna ask if you could talk about sunscreen. Because I learned and you taught me some stuff about sunscreen so good.

I think that the, the main thing is that there's been a paradigm shift in sunscreen. So when I was young, even, you know, my med school age, all we cared about was that SPF number. That was it. As long as you had a high enough spf, you'd be okay. You'll remember, sprays came along. Everybody was using sunscreen sprays. And then there, there began to be some concern about the safety of those and the durability of them. How long do they really protect you for, etc. But the paradigm shift now is that the number is a little bit less important than the formulation. And you're definitely seeing news stories about chemical sunscreen additives and whether or not we have appreciable levels of them systemically, because some of those things have no testing done on systemic absorption yet. Appreciable amounts are, you know, assayable. And those are going to be your ingredients. Like, you'll see very, very popular. One is avobenzone, and another one is octocrylene. Many salicylates and cinnamates are altered to be chemical sunscreens. So the paradigm shift is get a reasonable number. I mean, I think the American Academy of dermatology still recommends 30. I like to tell patients get 50. And I'll stick a pin in that. I'll tell you why in a second. But try to find a reasonably high number. But the much more important thing to drill down on is the active ingredient section only. Get titanium or zinc, because if your active section has titanium and avobenzone, you can put that in the category as a chemical sunscreen. One chemical in the active category, and it's a chemical sunscreen. Chemical sunscreens are the ones that people become allergic to. Chemical sunscreens are the ones that. That may have some safety implications down the road. Chemical sunscreens, they have one benefit, and that is they're a little more cosmetically elegant. They're a little bit more of a sheer finish on the skin. But for the life of me, I cannot find a rationale for that, because even the thicker mineral sunscreens that are a little tougher to rub in, they all end up rubbing in just fine. I think it's. It's just a mindset. People just like when their sunscreen bottle brags that it's going to be like you won't even know you're wearing it, you know, and so those need to go away. They are far, far inferior to titanium and zinc, which by the way are often compounded into vehicles that are much more adherent to the skin and so more durable.

I switched to the titanium and zinc sunscreen that you recommended to different ones and I like them so much better. It doesn't feel like I'm wearing sunscreen. It feel lot like, yeah, durable and it doesn't feel runny or any of that.

So perfect.

I gotta go through my basket and toss a bunch of stuff.

Well, okay. And I mentioned sticking a pin in the fact that you know the numbers a little bit less relevant. So when they test sunscreen. Stop me if you all already know this. When they test sunscreens, they use a shot glass quantity for a body covering. Nobody uses that much sunscreen in practice. No one. They're going to use, you know, maybe in the palm of their hand, a quarter sized, generous smear. And that's going to do face, neck, chest, arms. They might put a little bit more for that, but nowhere near a shot glass. So there is a dermatologist named Darrell Riegel. I think that he partially spends his time in Dallas. I think he's also in New York City. So I don't, I don't know if you all have heard of him, but. But to me he's like a local rock star because he's very, very. He's kind of a pioneer in skin cancer treatment. And Dr. Riegel talks a lot about sunscreen and he pointed out that if you are not going to do the proper quantity of your sunscreen, you might as well pump up the SPF of it and maybe you'll sort of correct for how insufficiently you're applying it. It. So there's a little benefit to that. You know, get the hundred because maybe it'll be. Maybe it'll all balance out and It'll be, you know, 40 when you actually put it on a tenth of the amount you're supposed to.

Yeah, I didn't know that, but that makes sense.

Yeah.

Well, I just want to ask, I mean, overall, do you love being a dermatologist? Are you glad you did not become an ENT or an oncologist?

I couldn't love it more. I. I like to say it is among my greatest blessings, my kids. But the fact that I ended up right where I am, I couldn't love the material more. Being a lifelong learner in dermatology is so rewarding. If you offered me a trip to like an exciting city or a trip that was going to be a really good derm conference, no question. I'm going to the Durham conference. I just enjoy it so much. It's better than, like a good book to me. I. Seeing and running through derm questions and seeing patients and trying to figure out what they have, listening to other dermatologists who figured out hard cases. It's true joy to me, so that I can't thank God enough for that blessing. And I think a lot of dermatologists feel that way. It's for other reasons because I think that the gratification they get from beautifying people, that's very subjective. But I think that's probably got to leave a lot of job satisfaction, too. But I'm so glad I ended up right where I am them. And I believe that more people need us than need the cosmetic guys. But, you know, personal. Personal belief.

Well, that's so great and encouraging to hear. I always ask all of our guests this. As we're wrapping up, we have a lot of different listeners on kind of different levels of the education path towards becoming a doctor. Do you have any advice for students like me who are just starting out on this long journey towards.

I do.

I do. I have regret and do this better than I did it. I'm sure many people who've gotten to chat with y' all have commented on the obvious conundrum, which is you finish residency and no one's really trained you for the business aspects that are going to be a very big part of your daily life as a physician. And I think that if you could kind of prevent the shock and awe of not knowing how to manage employees, not knowing, even down to things like what kind of insurances are you going to need to supply for your office? Are you going to. Are you going to join a private equity group? Like all of these business concepts, we didn't touch those in medical school, even in residency, to almost nil extent. And so my advice to you would be, don't end up being one of these people that says, like, oh, God, when was I supposed to know all this? This, because I promise you, on day one, it's expected that you're going to know it. The responsibility that you take on the minute you start seeing patients is all in total. So, you know, be prepared for that. And I. I had absolutely no inkling of any of it. I just learned what I do know, and I don't feel like I'm the savviest practice administrator by any means, but you just, you learn it gradually and sadly, you learn it when you screw it up. So what's that Old phrase, you know, having good experience. Experience comes from mistakes, mistakes come from having too little experience or whatever. But it's, it's hard to learn it after the fact. So the most you can soak in while you're training, the more you can soak in, the better. And another little piece would be, I cannot exaggerate enough how much I cringe at the damage that's been done to medicine as I knew it and your mom knew it generationally by insurance companies and you know, big pharmas had their hand in it. They definitely present a large barrier to good outcomes. It's so hard for patients to swallow some of the price tags of medications. But the insurance conundrum is so malignant because, you know, you've got either people trying to live in private practice and deal with insurance companies and have to see 50 people a day and employ this gigantic staff of people who do bewildering stuff with acronyms they're unfamiliar with and like processing stuff and denials and like every day the rules change. It's clown world insanity. And so with that having really taken hold your generation, I wonder what it must feel like going into it now. And I could look back and I can think, my dad had, you know, he, he was really in the heyday of like very, very lucrative medical careers. And then managed care came in kind of near the end of his career and he was devastated by it. Now, managed care, just that, that minute concept looking back, I'm like, that's not that bad compared to how much worse it got. And me, I, I opted out of Medicare in 2016. Best thing I ever did. And then I, of course have dropped all my contracts when I sold my private practice in Beaumont, but so plan to be able to run the whole business side of things. But the other piece of it is be developing a defense strategy for how much more oppressive the influence of the insurance industry may become on doctors. I mean, you know, you think about what's the worst case scenario if we were under a really, really liberal administration again, could they remove your freedom to practice medicine outside of a one payer system? I just, you always got to consider the worst case scenario. And if it got to the point where your joy from practicing it just was not commensurate with your reimbursement, what else would you do? I love seeing these doctors who also have an mba. The physician we mentioned earlier, whose podcast was before mine, he, he's got his mba, he can do a million other things. So think about trying to hedge and, and have another skill set, something that you could sort of diverge into. Because I do think there's the potential for a time when doctors are like teachers and, and policemen. They just underpaid for what they. Because the reimbursement per RVU or work order. I mean, you know this Sarah. It's pitiful. It's so unbelievable how hard you have to train and work for how little reimbursement now and it doesn't seem like it's getting any better.

Yeah, definitely important conversations that, you know, we need to start thinking about even this early in our career. So thank you for sharing and thank you for being here and talking with us. Where can people find you?

Your practices website or the practice website is. Is an easy place to find us. And so we're@rashdecisionsdallas.com and. And from there you can make an appointment, kind of surf around and see the different sorts of medical dermatology people come to us for and it'll give you some information on just how easy it is to come and see us. And yeah, I've really enjoyed talking to you both and it was an honor to get. To get invited to come do this. And so thank you both.

Great. Thank you.

Thank you. And you know where to find us @Generations MD on Instagram and TikTok and you can email us at Ask Generations and we will talk to you next week. Bye, guys.