The View from Under the Hood

Well, hello there, 2025! We have been waiting for you…some more than others, and definitely for different reasons. We have our new partner in crime and the ultimate Swiftie, Dr. Lisa Swanson, joining the squad to bring her Parks and Recreation vibe editorial style to us … buckle up, because she’s going to bring us to tears if she doesn’t cry first. Of course, we will never let Joel leave us for good. He’s the OG and foundation of what we started, and I can’t thank him enough for what he has done to make this journal what it is. We have a few new members of the editorial board, a few new ideas for columns, a few new digital programs like our relaunched podcast, and a few oldies and goodies that will never change … including my unhinged rants, which you can’t escape.

As I write this piece, I am on the way home from an 8-day round of meetings in both Florida and Hawaii, which makes perfect sense, of course. I barely got to exercise, see my kids, or even see the pool in either hotel, but it was still fun to see everyone as they start the year. Of course, who can resist making their resolutions, including the ever-popular Dry January. Interesting how resolutions that also might stick—using sunscreens, washing hands after lavatory activities, and expanding one’s horizons with a new hobby or language—don’t ever seem to make the headlines, but resolving not to drink on a day that ends in “y” has become a game almost as popular as Candy Crush.

One resolution I think might be best for dermatologists is to spend more time being doctors and see through problems. This, of course, involves letting people finish their sentences and not having multiple people talking at the same time, but also doing more detective work before coming to conclusions. This should apply to the time spent with patients, especially getting deeper into their history and spending more time examining them. Anyone who has heard me speak will know I use a lot of catchphrases, like “turn off the faucet” and “so now what?” But one of my favorites is “look under the hood.” Obviously, this sounds more like car trouble than medicine, but the time spent looking under the hood can be critical to making the tough diagnosis or to being relieved about starting systemic therapies. 

As 2025 brings new approvals for treatments for hidradenitis suppurativa, chronic spontaneous urticaria, psoriatic arthritis, and several other diseases that need answers, this is a good time for us to remember that the most important approach to treatment starts with the right diagnosis. We need to remind ourselves that psoriatic arthritis won’t diagnose itself. We must ask about the joints; it’s similar to how ocular rosacea won’t be a topic unless we ask about the eyes. Few will disagree that hidradenitis suppurativa is one of the most underdiagnosed conditions of the skin and patients often wait for years unnecessarily because urgent care clinics and many others outside of dermatology don’t recognize it and throw antibiotics at the problem. So, yes, the answer under the hood is to make dermatology great again…sorry, not sorry.

The biggest obstacle that we have looking under the hood might be that we don’t know what to look for. I had a patient once who was picking at his skin tags and when I asked him why, he said he thought it would fix them; it turned out he was an auto mechanic and I told him, “You know, I do the same thing when I have car trouble. I just take a hammer and start hitting everything under the hood until it starts to run,” to which he looked at me in horror. I smiled and said, “Are we on the same page now?” But the reminder is that if we don’t pay attention to what is under the hood and know what to look for, we might be just as bad as the guy swinging a hammer at the engine block.

The need to look under the hood doesn’t just apply to patient care; it resonates in the mirror, too. As we make the resolutions for the year, we should look inside and outside of ourselves as doctors and as people and make sure everything under the hood still works. How to take better care of ourselves, manage our time, and most importantly, set realistic goals that will actually stick should be the focus for 2025. The same goes with the next patient who comes in who doesn’t look you in the eye, who starts crying in the exam room, and who has more going on under the hood. Take the time to open the hood and see what you can find.