Thursday, May 17, 2012



author of

Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That are Completely and Utterly Wrong

What is your book Compartments about, and how'd you come to write it?
Compartments is about why people in different groups perceive the world in different ways. The book presents three premises: that there are things about other groups we do not see, that there is selection bias in what we do see of other groups, and that the shared context of our group affects our perceptions of the world. The book expounds on these premises through meaningful, yet entertaining stories.

The impetus to write the book came from a wealth of experiences in the medical world in which I found very good, very smart physicians to be at odds with and to have terrible misimpressions of one another. This led to the general concepts of how people in different groups—whether in medicine, business or politics—can be terribly off base about the perceptions of other people.

Who did you write the book for?

People who have grown tired of the growing animosity between groups and who want to see people get along better. The book is appealing to business people who want to better understand their customers’ perspectives or who want to reduce tension between divisions within a company.

The book is also perfect for book clubs that want something thought provoking to discuss.

Can you tell us about some of these important topics brought up in the book? 

A very important topic – why medicines stop working. For instance, patients tell their doctors that medications stop working, so doctors change to different (sometimes more toxic and costly) medications. Computer chips hidden in the caps of medicine bottles have shown doctors, however, that a key reason the first medicine stops working is that the patient has stopped taking it.

And then preconceived notions. That’s a topic of grave importance. Dermatologists see patient after patient whose skin disease was mismanaged by family doctors. Dermatologists know family doctors can’t effectively treat patients with skin disease. But dermatologists’ perspectives are warped because dermatologists see only the patients who were not helped by their family doctors, not the many who were well managed.

Also you’ll learn in the book how tanning beds are addictive, how people who work in the health insurance industry and drug companies aren’t all “bad,” and how people in other countries are often more like us than the news would lead us to believe.

How can we get people to get past their preconceived biases?

People need to be in the habit of thinking of the compartment they are in and how the walls of their compartment can act as a barrier to seeing what other people are usually like. Whenever we see or hear anything about another group, we ought to ask ourselves, ''Is that representative of what they are usually like?'' and ''Would people in their group—with their life experiences— look at this the same way I do?'' When we do have thoughts about people in another group—particularly negative thoughts—we should reach out to them and talk to them. Often we'll fine our preconceived notions are mistaken.

Have you considered writing a version of your book for children?

I've been asked to do it by teachers who have read Compartments. The principles of Compartments are basic to interpreting our experiences of other people. It would be great if we could teach our children not to make the same mistakes others have made.

What message do you hope to spread with Compartments?

Our world doesn’t need to be so contentious.

When people learn to see past the walls of their compartments, they often find that people in other groups are more like we are than we thought they were.

Also, how people view the world around them is a key issue, that we often hold negative views of people in other groups that aren’t correct. When people in one group try to tell us something bad about people in another group (and I hear that going on daily on the radio), they are usually well-meaning but wrong.

You travel to give medical lectures all over the country. Is your messaging received differently in each region?
No, people everywhere I've been—from across the United States, to the Middle East, to East Asia— have told me that more people need to hear this message. Well, I take that back. While people everywhere tell me that the principles are right, occasional listeners have told me in no uncertain terms that I'm horribly wrong about some specific group that listener doesn't like, that I have missed the boat about how evil people in some other group are, or how I'm missing my own bias. But the underlying truth, which isn't far from the Golden Rule, is generally well received.

Thank you for your time and for sharing this knowledge! Anything else you'd like to add?

I'd like to challenge the listeners to test my hypothesis. Pick out any group that you've heard negative things about—it could be people at another school, in another church, in another political party, in another division of your business, or in another country—and talk to one of them. See how well or poorly your preconceived notions reflects how they would describe or perceive themselves.

Where can we find your book?

The book is available through Amazon and Barnes and Nobles ( or through the Compartments website,


Dr. Steven R. Feldman is a professor of dermatology, pathology, and public health sciences at the Wake Forest University School of Medicine in Winston-Salem, North Carolina. He was born in Washington, DC, and attended grade school at the Hebrew Academy of Washington, a school that his grandfather helped to found. His family was active in the orthodox Beth Shalom Synagogue where Feldman attended services and had his bar mitzvah.

Feldman received his bachelor’s degree with a focus in chemistry at the University of Chicago. He received his MD and PhD degrees from Duke University in Durham, North Carolina, in 1985, following which he completed his dermatology residency at the University of North Carolina at Chapel Hill and his dermatopathology residency at the Medical University of South Carolina, in Charleston. Since 1991, he has been on the faculty at the Wake Forest University School of Medicine.

Dr. Feldman directs the Center for Dermatology Research, a health services research center whose mission is to improve the care of patients with skin disease. Dr. Feldman’s chief clinical interest is psoriasis. His passion is to help guide how patients with psoriasis are treated. He served two terms as a member of the Medical Board of the National Psoriasis Foundation, chaired that board’s subcommittee on education, and served as the director of the foundation’s chief residents’ meeting on psoriasis treatment from 2000 to 2005. He also served as chair of the American Academy of Dermatology’s Psoriasis Education Initiative Workgroup, developing regional courses on emerging psoriasis therapies. Dr. Feldman was director of the psoriasis symposium at the 2005 and 2006 American Academy of Dermatology (AAD) Annual Meetings and is a frequent speaker to lay groups, physicians, industry professionals, and managed care executives. He received a Presidential Citation from the American Academy of Dermatology in 2005 for his psoriasis education efforts and received one of the AAD’s highest awards, the Clarence S. Livingood Lecturership, at the 2006 AAD meeting.

Dr. Feldman has made significant contributions to understanding dermatologic health care delivery. His research team has focused on demonstrating the quality of medical dermatology services provided by dermatologists; defining the role of dermatologists in performing dermatopathology; assessing cost effectiveness of dermatologic treatments; and, most importantly, understanding the effectiveness, safety, and cost-effectiveness of outpatient dermatologic surgery. His research group has also published seminal studies on the dermatology workforce, the quality of life impact of psoriasis, and the reinforcing effects of UV exposure in frequent tanners. The work on tanning was covered extensively by major news media; Diane Sawyer interviewed Dr. Feldman concerning the implications of his tanning research on Good Morning America. Dr. Feldman’s research studies into patients’ compliance with their topical treatments helped transform how dermatologists understand and manipulate patients’ use of topical medications over the course of chronic disease. Dr. Feldman was awarded the Astellas Award (and its $30,000 prize) by the American Academy of Dermatology in 2008 for scientific research that improved public health in the field of dermatology.

Dr. Feldman founded the Medical Quality Enhancement Corporation and its Web site. The site is designed to help patients give doctors feedback so that doctors can enhance the quality of care they offer.

Dr. Feldman’s work has been published in over 400 articles in peer-reviewed journals, including top-flight dermatology and managed care journals. He has been a primary investigator or co-investigator on numerous industries, foundation, or federally funded research grants. Dr. Feldman has given over 600 invited lectures to dermatology groups and organizations. Since 1993, he has been a member of the editorial board of the Journal of the American Academy of Dermatology. He also serves as an editor of the Journal of Dermatological Treatment, on the editorial board of the Journal of Cutaneous Medicine and Surgery (the official publication of the Canadian Dermatology Association), the Southern Medical Journal, and Dermatology Online Journal, and as chief medical editor of Skin & Aging.

Excerpt from

Compartments: How the Brightest, Best Trained, and Most Caring People Can Make Judgments That are Completely and Utterly Wrong

by Steven R. Feldman, MD, PHD


You Can’t Trust What You Don’t See

Perhaps the best thing about being a doctor is seeing a suffering patient get well under your care. One of the most frustrating things about being a doctor is caring for a patient and not seeing him or her get any better. Often, patients do great. Sometimes, they don’t. Sometimes, the treatment just doesn’t work nearly as well as expected. And sometimes even when the treatment does well at first, after a while it doesn’t. In fact, one of the basic principles of my specialty, dermatology, is that after a while, the most commonly used medications—topical cortisone medicines— simply stop working.

The discovery of cortisone in 1948 revolutionized medicine and secured the 1950 Nobel Prize in Medicine for the discoverers, Philip Hench, Edward Kendall, and Tadeusz Reichstein. Kendall, a chemist, described the impact of the new medication: “On September 21, 1948, cortisone was administered to a patient who had rheumatoid arthritis. During the preceding five years she had continued to become worse and at the time that cortisone was given she was confined to her bed and endured much pain. Within a week she walked out of the hospital in a gay mood and went on a shopping trip for three hours without after effects” (Kendall 1953). As effective as cortisone was, even more powerful derivatives were created soon after. In the 1950s, cortisone formulations were developed that could be rubbed on the skin. These topical medications—medications applied to the skin—dramatically changed how skin diseases were treated.

While topical cortisone medicines provided a tremendous advance in the treatment of skin disease, their tendency to lose effectiveness over time limited their usefulness. This was a particularly difficult problem for people with chronic, incurable conditions like the one I specialize in treating: psoriasis. Psoriasis is a condition that causes red, scaly spots on the body. It is usually treated with topical cortisone medicines. The eventual loss of efficacy of topical cortisone treatments is so common and well characterized that it has a name: tachyphylaxis. Teachers of dermatology have, for generations, taught their students that tachyphylaxis can be defined as “the more you use the medicine, the less it works.”

Various treatment approaches were used to minimize the tachyphylaxis problem. Sometimes doctors would prescribe topical cortisone medicines to be used intermittently so the patient’s disease wouldn’t get used to the medicine. Sometimes treatments would be rotated from one approach to another in order to prevent patients from getting used to a particular treatment.

The concept of tachyphylaxis is simple enough. As people continue to use strong cortisone medicines, tolerance develops, and the medicine eventually loses effectiveness. Cortisone drugs work by binding to cortisone receptors in the skin. The loss of effectiveness makes perfect sense if continued exposure to cortisone causes the receptors for cortisone to disappear or to become less sensitive to the drug over time. This receptor desensitization theory provided a good explanation of why people who used the medication for long periods eventually developed tolerance to the drug.

But one thing didn’t quite fit the theory. If a patient became resistant to one cortisone drug, the doctor could prescribe a cortisone of a different brand—yet still of the same potency level—and the new drug would work just fine. The doctor didn’t necessarily need to prescribe a higher-strength cortisone. If patients had become resistant to topical cortisone because their cortisone receptors were reduced in number or in function, changing the brand of the cortisone should not have overcome the tolerance that had developed.

A small, simple research study turned theories about the loss of efficacy of topical treatments upside down. In the study, patients with psoriasis were given a gel to apply (6 percent salicylic acid gel, a safe medication commonly used to remove the thick scales that cover psoriasis spots) (Carroll 2004). The patients were told to use the medication twice a day. They were told that their use of the medication would be monitored, and they were asked to complete a daily diary of their use of the medicine. They also were asked to bring the medication back at return visits so the medication could be weighed. They were not told, however, that there were computer chips in the medication bottle caps recording their use of the medicine. Those computer chips didn’t just record the number of times the medication bottles were opened; the monitors recorded the day and time each time the bottle was opened or closed to see when patients actually used the medication.

The study found that the patients overreported their use of the medication (and that’s being generous). Some patients who hardly used the medicine at all recorded using it almost exactly as had been directed. One of the most important and interesting findings was that the use of the medication dropped steadily over time. Although the patients claimed they had been using the medication regularly as instructed, use of the medication dropped by about 20 percent every five weeks. The study lasted a total of eight weeks. We can’t know for sure what would have happened to the use of the medication after the eight-week study, but if that decrease in the rate of use continued, patients could be expected to stop using the medication entirely in twenty-five weeks or in about six months.

Dermatologists prescribe patients medications but don’t get to see what patients do with the medicines. Doctors prescribe in one compartment—their offices; patients use the medications in another compartment—at home. It had long been assumed that because patients’ skin disease bothers them that they would use their medications. It turns out many patients don’t use their topical medications as directed, and over the long run, their use of medication steadily drops. But dermatologists didn’t know this. Dermatology textbooks didn’t say anything about patients not using their medications.

Theories about how medications lose effectiveness over time changed completely. Dermatologists originally thought tachyphylaxis was “the more you use the medication, the less it works.” But tachyphylaxis was really, “the less you use the medication, the less it works.” Generations of brilliant professors of dermatology had been teaching their students the wrong thing, and generations of students of dermatology had accepted the traditional concepts. Dermatologists had no way of knowing that patients weren’t using their medicines until the development of electronic monitors in medication bottle caps.

The electronic evidence of patients’ use (or nonuse) of their medication didn’t just change theories about tachyphylaxis. Theories about all sorts of other dermatologic phenomena went kaput (Ali 2007). There was the phenomenon of children with eczema—an itchy, dry skin condition—that wouldn’t get better despite all attempts at outpatient management (Krejci-Manwaring 2007). These patients wouldn’t improve despite the use of potent topical or even oral medications. If the frustration with treatment and the severity of disease mounted high enough, these patients would be admitted to the hospital for treatment of the intractable skin disease. They would be treated with rather modest topical treatments, and they would clear up dramatically in just two or three days! For a long time dermatologists taught that these children probably did better in the hospital because they were away from the stress of the home environment, as if trying to sleep in a hospital bed is less stressful for a child than sleeping in his or her own bed at home. Now we know that hospitalized children with eczema improve, and they improve fast because in the hospital someone ensures that the medication is applied as prescribed.

There had been so much dogma about skin diseases and their treatment; some of which was patently ridiculous, and it was built up like a house of cards. All these ideas depended on the assumption that patients use their medications as directed. But you can’t depend on assumptions that you can’t test. A whole host of theories can be wrong, collapsing under the weight of a single inaccurate assumption. Learned teachers—even though they were brilliant, caring, and honest—could be completely mistaken.

We ought to be circumspect when we try to draw conclusions about things of which we don’t have firsthand knowledge. The immortal words of Donald Rumsfeld come to mind (Seely 2003):

As we know, there are known knowns. There are things we know we know. We also know there are known unknowns. That is to say, we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know.

We recognize that known unknowns are a problem. Rumsfeld cautions us that there may also be unknown unknowns that may cause us to stumble. But perhaps our biggest problem may be that the things we know we know just aren’t true.


Dr. Steven Feldman has written an extraordinary book. Provocative and often brilliant, Dr. Feldman has examined his own thinking and that of the medical profession in general, critically looking for patterns of misunderstanding between medical specialties and between physicians and others concerned with public health. Dr. Feldman courageously applies his paradigm of conceptual "compartments" beyond medicine to contemporary political conflicts, searching for new, more hopeful and productive ways of engaging with previously intractable conflicts. Regardless of occupational or political loyalties, all will benefit from reading "Compartments". Dr. Feldman's book contains many stimulating ideas, an unflagging idealism, a willingness to question received wisdom and the potential to shock readers into thinking outside the box of his or her own "compartment". 

Michael Sugrue, Ph.D., Professor of History and Chairman of the History Department, Ave Maria University

"Dr. Feldman has written an intriguing book that challenges you to examine beliefs held personally or accepted by society to determine if they are based on fact or appearance. This book has given me something to consider in the future from both a personal and professional standpoint. I would encourage anyone with a willingness to introspectively question his own views on medicine, politics or society to read Compartments."
Erika Borgerding, Medical Student
Winston-Salem, North Carolina

Michael Greenberg, MD

"Compartments is a brilliant analysis of why doctors and patients so often misunderstand each other. It also provides a glimpse behind the curtain that separates specialists like dermatologists and primary care physicians. The principles Feldman describes apply broadly in many areas beyond medicine."
Joe & Terry Graedon
The People's Pharmacy

"I recommend Compartments without reservation .... the book is going to affect me for a long, long time — hopefully for the rest of my life"
Ed Dewke
FlakeHQ (Full review at

"Compartments is dead on! In both my personal and managerial life, I have had the same experiences the book describes. I hope many people read it. It truly could help to make the world a better place!"
Albert Draaijer, Vice President of European/African/Asia-Pacific and Latin American markets, Central Marketing/Business Development and Communication
Galderma, S.A., Switzerland.

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