Steve Feldman is a question generating machine and maker of magic with tongue depressors. It takes an unusual mind to find links between medical research, mathematical models and world peace, but somehow Dr. Feldman manages to do exactly that.
Why dermatology?
I went into dermatology because I had a really bad case of poison ivy. At the end of the first year of medical school there was a day and a half of dermatology which I actually missed. But then, when I was in the lab there were a bunch of us MD/PhD students, and some of the candidates were sitting around talking about the rotations they did when they re-entered medical school. One of the first two rotations most chose was dermatology because they hadn’t done medicine for two years. So one of these other candidates came by to visit the lab and was talking about dermatology, and I remember vividly that I thought immediately “Dermatology! That’s what I’m going to do!” and I had no experience whatsoever to base that decision other than my history of poison ivy. My parents were like “what about cardiology?”
My PhD research did not tie in to dermatology at all, I studied alpha-2 macroglobulin and came up with a model for it. However, about two months ago I was attending a meeting and there was a talk on this injectible collagenase product and how the body inhibits foreign bacterial collagenase, and then they say it’s alpha-2 macroglobulin and they put up a picture of my model, and there is a tiny citation at the bottom of the slide with my name and one of the astute dermatologists in the audience who notices every detail, Jeff Callen, says to me “Is that you?!” and I’m like “yeah, that’s me”. So that’s the one time in dermatology that my PhD research has been relevant.
Jorizzo hired me at Wake Forest to run the test-tube lab. He was absolutely determined to build a great department and thought that you couldn’t do that without test-tube science. He hired me to start and build test-tube research at Wake, and I was a total failure, so you can put me down as that “Steve Feldman: total failure”. But seriously, Jorizzo gave me many degrees of freedom. When he hired me, he also hired Alan Fleischer, and Alan and I had done residency together at Chapel Hill. Alan and I started collaborating together, early on a health economist told Alan about this survey the federal government does called the “National Ambulatory Medical Care Survey”. So we looked at it and I had this background in science that taught me how to ask questions.
Using this survey, we just started publishing like crazy, and it was all about how you need dermatologists, because this was during the early years of managed care and we were concerned about being marginalized as a specialty. One of the things that inspired us was an article a family doctor wrote in JAAD saying why it was important to see a family doctor if you have a skin problem, because most skin problems are simple and they will not only help your skin, but they will address all of the patient’s needs in a clinic visit: counsel patients on other things, check blood pressure, etc. We showed using the national care survey that everything he said was false, that dermatology problems are often complicated and that most FPs will require several visits to do counseling and deal with multiple problems.
After some of our papers came out, I was invited to go to Dartmouth to the Center for Health Services Research, and I said to Alan “we should have something similar for dermatology”, because there was a big concern that by the year 2000 all dermatologists would be driving taxis because insurance plans would drive their patients to see family doctors. So sure enough, we got the biggest dermatology drug company to fund $1M over 5 years to fund our work. Then we were sitting pretty and could do any kind of research we wanted to. This attracted students from all over the place that wanted to get into derm because they knew if they came to spend a month with us and worked hard, they could have a couple of publications by the end of the rotation.
Because we had all of this support, we could ask all sorts of questions, and one of the things I wanted to do was to study why people go to tanning beds. So I went to a Society of Investigative Dermatology meeting and I thought that I should read all of the posters, and there was this poster by Mina Yaar who was working with Barbara Gilchrest up in Boston. They were interested in pigmentation and they had irradiated skin cells and demonstrated that the skin cells produced alpha-melanocyte stimulating hormone, which is a derivative of pro-opiomelanocortin, which they showed goes up. I was like “Oh my god, when you radiate skin cells you’re making endorphin!” And I was like, ”Nina, you just explained why people are going to the tanning beds.” because after a while, it doesn’t look good– like tan mom, but you ask these people why they’re tanning and they say because it’s *so relaxing*. So I had the idea to do the two tanning bed experiment and demonstrated that people chose the UV bed when given a choice. One of the things I remember from my PhD years was something that Irwin Fridovich commented on after a lecture. He said “If you want to know if something is causative, you have to use a specific inhibitor.” This stuck with me, and it was this comment that gave me the idea to give the tanning bed users naltrexone to see if it changed their perception of the tanning bed, which it did.
It sounds like your training in your PhD helped train you to ask questions, even if you didn’t apply that to bench or ‘test tube research’
Yes, it also taught me to be fearless about using whatever technology I needed to use. I did the PhD because Duke forced me to. In undergrad at the University of Chicago, all I took was chemistry, physics and math, and then my advisor realized that I needed a more well-rounded education so I took an economics class which was really interesting. So when I got to Duke, I said that I wanted to do my PhD in economics, but this was in 1981 and health economics was in its infancy and so Duke said no, that I had to do it in basic science. So they missed the boat and forced me into a test-tube lab. It wasn’t until I ended up working with Alan Fleischer who had studied epidemiology, with our complimentary skills and Jorizzo giving us the freedom to do what we wanted that we were just very effective.
I’m a kid in a candy store, I just pick low-hanging fruit, like the time that one of our dermatopathologists said “Everybody knows that the plastic surgeons have positive margins more often than the dermatologists.” and I was like “WHAT?!” this was around the time that surgeons and anaesthesiologists were promoting regulations to try and restrict what dermatologists were able to do surgically in their [dermatologists] offices. So we got one of our minions, Aaron Katz, to pull all of the skin cancers that had been excised at our institution. We ended up making a multi-center study, and we showed that dermatologists had positive margins 6% of the time, the plastic surgeons on average had positive margins 40% of the time, and the ENT doctors over 50% of the time. Well, the dean at Wake was an ENT doctor, and the PR department at Wake thought this article was important and decided to put it on the cover of the school’s internal newsletter that sits in the lobby of each clinic. Well, this dean hit the ceiling and wanted us fired, and he called Jorizzo, who was totally supportive of us and just backed us up and said that we do good work and that he wasn’t going to fire us. So the dean called Alan and me into his office and he’s mad, he was like ‘this is irresponsible and you need to be more collaborative, and should have included us in this study and we shouldn’t have found out about it this way.’ We agreed and told him that the next phase of this study was to examine the relative cost of removal. Because dermatologists do these at very low cost, whereas surgeons do excisions in the OR at high cost. We asked him if he could identify a surgeon to collaborate with us on the next phase. You should have seen the steam coming out of his ears. Fleischer and I are not the most PC of people.
When do you feel flow and lose track of time doing something?
Well I think when I try and think of a very complex problem, like in my PhD I was trying to come up with a model of alpha-2 macroglobulin and wanted something that would capture everything that I knew about it. I feel this way when I think about some of the things we do in dermatology, like when we counsel patients about tanning, I try to make an economic model of people’s behavior. You look at how much an activity like tanning benefits them, and what the risks are, and you can integrate the sum of that over time. But here’s the thing: the benefit of the tan happens this weekend, when you’re trying to get a date, and the risk happens fifty years later. So you do this integral, you multiply the benefits and the risk by E to the minus sigma t, and that discounts the future values relative to the current values. The idea of counseling people about what happens in the future makes no sense from a benefit perspective because of how people discount future risks. Talking about future risk is basically stupid because it won’t change behavior. So what you have to do is put pale untanned skin on the cover of magazines to change society’s perspective about what will get them a date this weekend, thereby increasing the present value of sun protection.
I’m very interested in behavioral economics and how it influences behavior. The human mind is funny in terms of how it latches on to things. Are you familiar with any passengers United Airlines flew this past year? Yep, we all know about that one guy who was dragged off the plane. One anecdote is generally more powerful than a whole book of data. So I will talk about getting a golf ball sized tumor and needing to get half your nose removed and having to wear a rubber prosthetic and how using sun protection can prevent that, instead of just talking about preventing skin cancer in general. Positive anecdotes work similarly, if there is a patient who needs a certain medication but is doubtful in some way, I will talk about how a similar patient did well on that medication, which usually convinces them to try it.
All of this research into patient behavior has made me very interested in world peace. Just like the anecdote in clinical medicine, people latch on to individual stories. There are over 1.5 billion Muslims praying for world peace 5 times every day, but we only hear about the ones who do something bad, so then Americans start to think that Muslims are evil all over the world. It’s the same type of misperception. This lack of being able to see things from different perspectives is a major source of human conflict. I gave a whole Livingood lecture at the plenary session of the AAD on how two people can be looking at the same exact issue and see totally different things.
What aphorisms do you hope stay with your residents in their future careers? 
Fleischer probably had more of those that I did, but one of his that I really like is “Uncommon manifestations of common diseases are more common than common manifestations of uncommon disease.” My residents tell me I’m known for the magic tongue depressor. If you google it, you’ll see what it is.
To what do you attribute your success in publishing?
First, I have all of these minions that want to get into dermatology and they want to be productive, and they are disappointed if I don’t give them a lot of work to do. So the first thing I do is give them the manuscript template file. I also have very low standards. We have a rule: no paper is unpublishable unless thirty dermatology journals have rejected it. Each rejection is one step closer to acceptance. I also try to have a clean desk. I try to address things students send me right away. People come to me because I’ll get stuff done.
You’re also kind of a research question machine.
A question machine! That is true, I question everything.