My Days In Dermatology

I’ve always been good at pattern recognition and my visual/spatial orientation is excellent. Photography is my hobby, so it was only natural that as a medical student and internal medicine resident, I loved my dermatology electives.  Each day yielded up a new parade of interesting skin lesions and rashes, and by the end of my rotations I was confident in my diagnoses and recommendations—contact dermatitis?—steroids!  Eczema?—steroids!  Psoriasis—yep, you got it—steroids again!  Pimples?  Well that was a diagnosis that required antibiotics.  But sometimes, when it was really bad—yes, STEROIDS!  These were the days before Botox, and Restylane, and non-invasive mini-lifts, and lasers.  Occasionally there was the excitement of a skin cancer, or a truly serious life threatening dermatologic crisis, but as much as I enjoyed saying the words “pemphigus”, or even “bullous pemphigoid” (try it—they roll right off the tongue)—I didn’t want to spend my career looking at it.  I chose radiation oncology after my internal medicine residency, and never looked back.  I wanted to take care of sick people.

When I announced my retirement in February, the calls started coming in immediately.  Having moved several times since I graduated from medical school, I hold medical licenses in three states which makes me a prime candidate for companies who supply locum tenens or “hired hands”– doctors who cover practices while the regular doctor goes on vacation, takes maternity leave, or just needs a break.   I was vaguely interested, but not enough to commit to spending weeks away from home living in a hotel.  But then a call came in from my old group, a Los Angeles based practice that had just set up a skin cancer treatment unit in a San Diego dermatologist’s office.  The hours were reasonable, and the job was only two days a week, covering while the regular radiation oncologists took their summer vacations.  This type of radiation machine, called the Xoft, is fairly new and uses a miniaturized high dose rate X-ray source to apply radiation directly to the skin cancer, while minimizing the dose to surrounding tissues.  For basal cell and squamous cell skin cancers, the results are extremely good, with excellent cosmetic results providing a great alternative to the Moh’s procedure which can leave patients with a significant “divot” in their faces, sometimes requiring skin grafts.  Dermatologists can buy these machines, however they are not legally allowed to operate them, having no training or background in radiation therapy.  That’s where I come in.

For the last two weeks, I’ve spent Mondays and Wednesdays in the dermatologist’s office.  It is a remarkably busy office with seven exam rooms going at all times, an operating suite and numerous medical assistants scurrying around with headsets on to communicate with Central Command.  The atmosphere is similar to what I would imagine the air traffic control room is like at JFK.  No one ever goes to the bathroom or takes a lunch break. There are flat screen TV sets in every exam room, to entertain the patients while they wait (try explaining skin cancer treatment with radiation to an 86 year old with bilateral hearing aids watching an episode of “24”—challenging to say the least!) As the physician in charge of radiation, I must set up each patient to make sure the applicator is placed correctly.  This involves a brisk walk down a long hallway from my makeshift office to the radiation room many times a day.

In the middle of that hallway, mounted on the ceiling, there is a television which runs a continuous infomercial about the joys of cosmetic dermatology.  It took me a few passes to notice it, but once I did, I was mesmerized.  The pulsatile blue light of the laser erasing wrinkles, the miniscule needles injecting the varicose veins, the tightening of the dewlap under the chin and the apparent dissolution of fatty deposits in the wrong places and their magical reappearance to plump the cheeks and add youth to the lips were hypnotic.  A head-setted medical assistant colliding with my ample in-need-of-liposuction derriere brought me back to reality and the skin cancer patient waiting.

I am beginning to see some advantages in my current part time job.  I smile brightly at the dermatologist in his scrubs.  He is an MD-PhD and very smart to have hired radiation oncologists to treat his skin cancer patients.  I have a new admiration for the tools of his trade.  I think that if I am really diligent, I might just get a free consultation and who knows—with a little buffing and polishing and injecting—a whole new face!

There Comes a Time

Written while returning from my Galapagos trip, posting now.

It’s happening—the moment that we all dread as we age, that point in time where we realize that we are becoming our parents.  When I was a child, my father was a busy man, completing his residency in plastic surgery, establishing a practice, climbing the academic ladder.  He didn’t have much spare time for us kids, but occasionally he would make an effort to take us on an outing—the circus perhaps, or the zoo.  On those outings, I remember one thing above all.  As we walked along beside and behind him, he would methodically point out every physical imperfection he could see on passersby—a bulbous nose here, a weak chin there, a jagged scar perched on an otherwise perfect cheek or a poorly repaired cleft lip.  The world of the unbeautiful was his oyster and he knew what to do to fix it.

On our recent trip to the Galapagos Islands, I found myself scanning faces and bodies in a similar fashion, but I am no Pygmalion out to transform the luckless Galatea’s of the world.  What my roving eyes were seeing under that equatorial sun were skin lesions aplenty—a benign nevus here, a senile keratosis there, but then, more importantly, an obvious basal cell carcinoma above the upper lip of one of my fellow explorers.  And then came my dilemma:  do I say something to the hapless traveler?  Can I convey in a casual sentence or two, “By the way Joe, you have a skin cancer on your face.  You should have that looked at when you get home, but don’t worry about it!  It isn’t a melanoma, the life threatening kind of skin cancer.”  What to me is a simple helpful hint might be to my companion a bomb dropped in the middle of that peaceful archipelago.  I took the easy way out.  I exercised my right to remain silent rather than risk ruining his vacation.

There was one incident, however, on a bumpy Zodiac ride from the good ship Endeavor to our first sandy beach landing for snorkeling.  Our naturalist guide Xavier had applied a coating of zinc oxide over his nose and cheeks so thick it looked like Comanche war paint.  Yet still, that greasepaint could not disguise an obvious bump arising from his right malar prominence.  He admitted to me that his doctor in Guayaquil wanted to “cut it off.”  Quickly I motioned for my father and together we performed the first National Geographic skin examination of the tour.  As the zinc oxide was wiped away, simultaneously we crowed, “It’s benign!!!”

A day later, Xavier admitted to me that he was so relieved he called his wife and children on the mainland to tell them the good news.  Have I mentioned that dermatology was a field I strongly considered while in medical school?   Reporting from afield…. Miranda.

Finding Your Way Home, Again

But all great voyagers return 

Home like the hunter, like the hare

To its burrow; below, earth’s axle turns

To speed their coming, the following fair

Winds bless their voyage, blow their safe return.

 Barbara Howes

Today I saw an 80 year old patient with skin cancer—not a melanoma—the dangerous one, but a routine garden variety basal cell cancer sitting right on the edge of his nose, where the nose meets the skin of the cheek. His surgeon told him that he could cut it out, but that there might have to be a flap rotation or a skin graft to fill the gap, and the patient declined surgery.  As a result he was referred to me.  After hearing about radiation, this nice man decided to go ahead with treatment, but he had one question—could he wait until after the holidays?  The reason was that all thirteen of his grandchildren were coming to visit him, and bringing his first great grandchild.  I reassured him and told him that of course he could wait—the treatment of skin cancer is never an emergency, and while he might sing “Rudolph the Red Nosed Reindeer” to his grandkids, we didn’t want him to look like that famous deer!

My daughter arrived back in Texas yesterday after travelling since Thanksgiving on the residency interview circuit.  She has covered both coasts and eight different cities since showing up on in San Diego just before the holiday. She said it was good to be home, even though she misses her cat, who remains here with me during her travels.  I sense a grown up transition in the transference of “home” from being here with her parents, to “home” being her own condominium in Houston.  Although I miss having her around, I am happy that she has found her own ground, and her own friends, and made a life for herself there. Her biggest job in the next few months will be to figure out just where her next home will be, for the next three to six years. The best advice I can give her is to choose her next move based on her comfort with the people she has met along the way.  Not only will they be her peers and her mentors, but they will most likely resemble her “family” in the coming years—she will spend more time with them in the hospital where she lands than she will with any of her real family members.  For newly minted doctors, the hospital where they do their training becomes home.

I am glad that Christmas Eve and Christmas Day fall on a Monday and Tuesday this year.  My department will be closed both days, which will give my patients a four day weekend.  For some, this means they will get to take a trip home, wherever that may be.  For others, the four day rest will give them some relief from the side effects of treatment.  For those of us not undergoing treatment, may the fair winds blow your friends and families to you, or you to them, and safely bring you home.