How to Navigate Difficult Situations

Physician assistants can encounter a variety of difficult situations at their practice outside of the typical dermatologic care. From discussions about mental health with your patients to diving into intimate partner violence and sexual function, these are all conversations that can make anyone uncomfortable.

However, Melissa Mauskar, MD, associate professor in the departments of dermatology and obstetrics and gynecology at UT Southwestern Medical Center in Dallas, Texas, reveals some tips and tricks for navigating these difficult situations in her presentation at the 2022 Society of Dermatology Physician Assistants Annual Summer Meeting held in Austin, Texas, from June 16-19.¹

Mauskar started off by providing 3 mock scenarios in which her office staff enacted actual previous encounters with patients that involved discussing intimate partner violence and mental health.

When it comes to psychiatric conditions, such as depression, which is experienced by 30% of dermatology patients, Mauskar suggested screening for secondary psychiatric concerns in at-risk patients. However, there can be obstacles to this secondary screening, including a lack of clear guidelines, screening falling outside the dermatology domain, and a lack of time in busy clinics. Also, patients might now volunteer mental health information and clinicians don’t always pursue further action even when mental health problems are found.

To combat this, Mauskar recommended implementing the PHQ-2 in Dermatology, which screens for depression and suicidal ideation. The benefits of this screening tool include being able to catch unrecognized patients who fall between the dermatology and psychiatry domains, helping clinicians recognize and screen patients for mental health concerns, and helping refer those patients for appropriate care.

She also noted that when a patient is diagnosed with a chronic condition, they can become more anxious or depressed. The reverse is also true for patients who are already experiencing anxiety and depression, which can manifest into a serious physical disease, and halt the ability to withstand or recover from one.

Moreover, the longer mental illness is left untreated, the more significant an increase in the risk of developing a physical illness or disorder, which results in behaviors that can make mental illness worse.

If you encounter a patient that expresses issues with their mental health, Mauskar recommended suggesting lifestyle modifications to your patients, such as exercise, counseling, and mindfulness mobile apps. She also mentioned possibly prescribing medications including gabapentin, escitalopram, and duloxetine.

Intimate Partner Violence

Another topic Mauskar touched upon was intimate partner violence, which is defined as physical, psychological, economic, or sexual violence that occurs between current and former intimate partners. She added, “Although men are also affected, 1 in 3 women worldwide will experience physical and/or sexual intimate partner violence in her lifetime.”

Moreover, the US Preventative Services Task Force recommends that clinicians screen for intimate partner violence in women of reproductive age and provide/refer women who screen positive to ongoing support services.

Dermatologists are uniquely situated to view physical injuries and assume long-term care relationships, which may increase disclosure and improve linkage to health care services,” Mauskar said. “Remember, you can make a difference.”

If a patient discloses they are experiencing intimate partner violence, Mauskar suggests providing emotional support, referring the patient to appropriate services, and forming a safety plan. Additionally, physicians are required to inform child protective services or law enforcement if there is a reasonable suspicion of abuse or neglect of an elder or child patient.

Finally, Mauskar concluded that all clinicians should normalize screening using standardized questions, and regardless of if they are experiencing intimate partner violence, they should offer information to all patients.

Reference

1. Mauskar M. Communicating in difficult situations. Presented at: The Society for Dermatology Physician Assistants Annual Summer Meeting. June 16-19, 2022. Austin, Texas.