Seeing the Full Picture

With the new year, it seemed like a good time to do some home maintenance. I had a plumber come out to do an annual checkup on our home plumbing. The timing was perfect because I had just discovered that my son plugged up a bathroom sink with his beard trimmings. The plumber had a hard time clearing the blockage, and he recommended about $1000 worth of additional drain snaking. I asked him whether Drano might fix the problem. He told me that he has a lot of customers who have tried Drano, and, in his experience, it never works.

I was not surprised that he said Drano does not work. If someone has a clogged drain and they successfully use Drano to clear it, would they be likely to call a plumber to fix a problem that no longer exists? I imagine the only time people call the plumber is when the Drano does not solve the issue.

I think my experience with Proactiv for acne is similar. I have seen hundreds of patients with acne who tried Proactiv. I do not remember any of them saying that the Proactiv cleared up their acne. But I am quite confident that Proactiv works for a lot of people. When people are happy with the results, they are unlikely to come see me for acne management advice.

Such selection bias has a huge impact on our perceptions. As dermatologists, I think we may underestimate the quality of skin care offered by primary care providers because it is likely we only see their failures, not their successes. And I do not blame surgeons who hold a low opinion of the surgery performed by dermatologists; it is much more likely that they see the few patients who are unhappy with their results rather than our many patients who are pleased with the outcome.

If you want to know if a drug works, it would be better to see clinical trial results than to rely on patient experience alone. Clinical trials are extraordinarily valuable; however, drugs proven effective in clinical trials may not work for our patients if they are not accessible. In this issue, we discuss setting up clinical trials in the office and examine the cost of treatments and delays in insurance coverage. We also cover current trends in dermatology health care management and the link between hidradenitis suppurativa and depression, among other topics. As we consider new information, it can be helpful to question whether we are seeing the full picture. Too often, biases can get in the way of accurate understanding. Consider this New Year’s resolution: to be on the lookout for what we do not see.