Difficult conversations are a routine part of dermatology. They are especially tricky in our specialty because of the time pressure in a full clinic (often 30+ patients a day) and the visual, often deeply personal, nature of skin disease. Medical school teaches universal communication techniques, such as active listening, teach-back, agenda setting, and shared decision-making, that are necessary to establish patient relationships. However, they don’t tell you what to say when a patient walks into an appointment with 10 squamous cell carcinomas or has severe psoriasis and is afraid to start a biologic. The tips below are meant to fill that gap; approaches to common dermatology clinic scenarios that you can use to improve patient outcomes and the flow of clinic.
1. Elderly Patients with Multiple Skin Cancers
Many of my elderly patients tell me, “Getting old is not easy”. Elderly patients can face mobility constraints, cognitive impairments, lack of access to transportation, and an inability to receive help with wound care. It is important to pick up clues about their lives as the appointment unfolds. Do they arrive in a wheelchair? Do family members bring them in? Do those family members take time off of work to bring them in? Does it take them more than ten minutes to get undressed? Are they winded after getting undressed? Do they complain about having to travel to clinics so frequently? All of these insights shape the conversation and direct discussion on treatment options.
Here’s how to help patients and families set realistic expectations and land on a plan they can actually sustain:
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- Be specific about the number and frequency of visits a treatment will require, and how much wound care it involves.
- Ask directly about transportation and access barriers. Acknowledge that repeated visits are a real burden, and offer alternatives where they exist (topical therapy, field treatment, or coordinated wound care).
- Frame prognosis in proportion to the disease. A patient with a low-risk basal or squamous cell carcinoma may well outlive their cancer risk, while a patient with an aggressive subtype needs a different conversation. For the former, explain conservative or palliative approaches that are minimally disruptive to the patient’s life.
There is rarely a black-and-white answer in these circumstances. Medicine is a partnership, and creating a treatment plan that a patient can actually follow through on is often more valuable than the one a guideline would rank first. Whatever you decide together, document the conversation thoroughly.
2. Patients Hesitant About Systemic Therapy
Many patients have concerns and questions about starting long-term medications. Who can blame them! They want to be confident about what is going into their bodies. Approach these conversations as a chance to explore what would improve the patient’s life, not as a negotiation you need to win. Some strategies to consider:
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- Find the root of the hesitancy first. Questions like “What have you read or heard?” and “What worries you most?” surface real concerns, such as immunosuppression, malignancy risk, cost, bloodwork, or time commitment. You can’t address a fear you haven’t named.
- Consider the risks of not treating. Untreated psoriasis can lead to cardiovascular disease, metabolic syndrome, and progression of psoriatic arthritis.
- Help them picture the path forward. When might the itch or rash start to improve? What do the first few months look like?
- Share what treatment has meant for other patients. Patients on a systemic medication spend less time applying daily topicals, covering up rashes, and worrying about how others perceive their disease.
- Give them additional educational material. By recommending professional organization guidelines, manufacturer websites, and published trial data, you can empower the patient to learn from trustworthy sources, instead of leaving them to sort through the internet alone.
It often helps to plant the idea early. If a patient with severe psoriasis wants to stick with topical treatment, you might prescribe a topical treatment but also say “If this doesn’t get things under control in two months, I’d like to talk about an oral or injectable option at your next visit.” That gives them time to sit with the idea before they have to decide.
3. Patients Who Are Concerned For Infection
This group ranges widely from a patient worried about a healing surgical site or inflamed cyst to those who present with delusional parasitosis. For the latter group, here are a few approaches that help:
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- Validate the suffering without validating the belief. A phrase like “This is clearly affecting your day-to-day life” acknowledges what the patient is going through without confirming a cause.
- Frame testing as a process. Negative results rule things out, which you can point out provides reassurance without being dismissive.
- Introduce psychiatric co-management carefully. It is helpful to talk about the mind-skin connection and the role the brain plays in perceiving sensations. This lands very differently than saying “I think this is in your head.”
- Set a follow-up cadence that reassures you care, while avoiding unnecessary escalation of testing or treatment.
- Gently propose bringing another family member or friend to their next visit. It is often helpful to have another set of eyes and ears in the room to provide more insight into the patient’s life and experience.
More commonly, the concern for infection comes from patients who recently had a procedure or an acutely inflamed cyst. Remember that patients have not been trained to recognize normal healing or distinguish inflammation from infection. Redness, tenderness, and swelling are understandably alarming, especially when patients are surrounded by antiseptic products both online and in drugstores. Review the expected appearance of a healing surgical site and describe the warning signs that should prompt a phone call. The combination of an explanation plus a clear safety net builds more trust than reassurance alone.
Ultimately, difficult conversations are not won or lost in a single visit. The goal is to build trust, understand each patient’s circumstances, and create treatment plans that are both medically appropriate and realistically achievable.
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