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!

Who We Really Are

When I was a resident in radiation oncology, I thought I already knew a lot about medicine.  After all, I had just completed an internal medicine residency, and had taken and passed my boards.  Needless to say, I was more than a little bit irritated the first time a patient “coded” in the radiation therapy department and I was shoved out of the way by the intern on the code team.  After all, he was an internal medicine intern at the World’s Greatest Hospital, and I was a lowly radiation oncology resident. My protestations of “I can HANDLE THIS!” were lost in the general hubbub of excitement and confusion surrounding a cardiac arrest.  The patient survived, despite my bruised ego.

I found out very quickly that I didn’t know much at all—in fact, I didn’t know how to write a proper history and physical.  On my first rotation, my attending corrected my very first sentence, stating emphatically that “Mr. So and So is NOT just an 86 year old Caucasian male who presents with lung cancer. He is an 86 year old retired firefighter and grandfather of eight who presents with lung cancer.  There is a big difference.  You will see!”  From that point on, I was charged with adding descriptors beyond the age, sex and race of my patient so that I would know that patient as a PERSON, and not just as a disease.

My daughter is going through her internal medicine residency right now.  I remember how easy it was to de-humanize a patient by calling her “the myocardial infarct in ER bed 8”, or the “renal failure in 222”, or the “nursing home placement on the 9th floor”.   If we call them by their disease, they cease to be the living breathing mother of high school age twins, or the father of a disabled son, or the principle of the local school for the deaf.  They’re just diseases, to be treated and discharged, or “buffed and turfed” in the old House of God parlance.  It’s much easier to be detached from a disease, than from a human being that one might just have something in common with.

Because of my first radiation oncology attending, to whom I will be forever grateful, I’ve made a point to pay attention to the person, and not just the disease.  I teach my medical students the same thing—that it’s not enough to just copy and paste the social history—the history of whether the patient is married, has a profession, has children, smokes or drinks alcohol or takes her religion seriously.  I try to learn about the person, and when I do, and convey that to my entire team of physicists, therapists, nurses and front office, I know that the patient gets better care.  It’s just human nature to empathize, and sympathize, if we truly know the human being behind the diagnosis. And it’s especially true for the difficult patients, the mean and angry ones, the ones we would prefer to dismiss.

But sometimes I slip up.  Recently I treated an elderly man postoperatively for rectal cancer.  He was a quiet elderly gentleman, but his son, a tech writer, made everyone in the department miserable with his demands for his father.  I never asked the man what he used to do, before he was eighty six with rectal cancer.  But another one of my patients was a little more curious.  He and the old man were side by side in the waiting room day after day of treatment until finally, the younger man asked me, “Where is Mr. __ from?  I can’t place his accent.”  I said, “I don’t know—I suspect he might be German but I never asked.”  So I did ask.  And was surprised to find out that my elderly patient was Israeli, born in 1925 in what was then Palestine. A true “sabra.”  He grew up in the Holy Land to become one of Israel’s foremost songwriters.  In fact, they still play his songs in Israel and recordings are available on YouTube. And I would never have known that if another patient had not cared enough to ask.

When you and I get sick, as we almost certainly will, we should all hope that our histories state who we really are, and that our admitting interns and residents care enough to ask.  They will be better doctors if they do, and we will get better care.

Dear Diary

I was talking to a friend the other day about the fact that what we now call “blogs”, we used to call diaries.  Then I said to her, “I should pull out the diaries that I kept in college and in medical school and see what my old self had to say.”  And so I did.  The first entry was October 28, 1974.  The last one was June 10, 1977.  After that, I just got too busy to write anything down—that is, until now.

One thing is for sure—I didn’t want to embarrass my future self.  I was so much more discrete back then.  I hardly ever mentioned anyone by his or her full name, which is a shame now since I cannot remember who the heck B.C and E.S  were, which somehow dilutes the profundity of my observations about them.  And I left out the really juicy parts which is even more of a shame—I mean, isn’t that what diaries are for?  Certainly not to quote Cat Stevens, which I did rather liberally, and with great feeling.

Still, upon review, there were a few things that I read tonight where I recognize the self that I have become.  In February of 1977, on my core Internal Medicine rotation, I watched a 34 year old man die of complications of lupus, a disease which was significantly less treatable then than now.  He had developed pneumonia, with fluid on both lungs which required chest tube drainage.  I wrote, “He’s been asleep since we let the fluid out.  Sometimes these days I have to turn my head and walk away from a patient’s bed so that they won’t see that I’m crying.”

In March of 1977, I had started my general surgery rotation.  I wrote, “Today I wheeled a patient out of the operating room into recovery, a nineteen year old girl who woke up from the anesthesia screaming, “Don’t let my Daddy rape me again!  Please don’t let my Daddy rape me again!”  I wonder what the hell I am doing here.”   That day I wrote a letter to a friend, saying, “I am so happy that you’re still here watching and listening and caring.  I mean somebody better be, because no matter what they say about life being too short and all, it seems like this is going to be a long haul.”

And the last entry, June 10, 1977—“What seemed so menial, so mundane becomes the only way.  Medicine is the only way.  I think I see now; medicine is not for those who hate and fear death, but for those who hate and fear loneliness.”

Sometimes it’s nice to look back and see that somehow, it all worked out.

For Once, Then, Something

As I was leaving for Boston, I asked if anyone would care to contribute to this blog.  I am still processing the wonderful things that friends and family have sent me.  This one is from my husband.

One drop fell from a fern, and lo, a ripple
Shook whatever it was lay there at bottom,
Blurred it, blotted it out. What was that whiteness?
Truth? A pebble of quartz? For once, then, something.    Robert Frost

Our daughter is in the last year of medical school and is having a hard time deciding what career path to take. She has applied for a residency program in internal medicine, but a recent experience with her grandfather in Africa where she was able to assist in the surgical repair of a variety of physical deformities has made her wonder if a career in surgery might be a better fit.

Choosing a career is a really big deal. Since most of us have to live with the choice – good or bad – for much of our adult lives, it’s a decision not to be taken lightly. This is particularly true in medicine, where the training is long and arduous, and by its very nature is not something you want to repeat again should your first career choice not work out. Yet, there aren’t many “how to” books written on the subject, and few of us feel comfortable directing someone else along a career path that might not work out for them. So, what advice – if any – might I give my daughter?

Based mostly on personal experience and some library research I performed as an undergraduate, I suspect that many of us choose a career based on a “gut” feel. Sometimes a career just feels right. Perhaps it’s the intangibles or maybe just good fortune. I know in my case it was a little of both.

My daughter recently asked me how it was that I ended up being a pulmonary physician. The question brought to mind how many different career paths I actually explored along the way. Once, I wanted to be a psychiatrist. This was at the beginning of medical school when I was fresh from spending endless hours listening to the sometimes neurotic musing of my college friends. Hey, this was interesting and could be fun, particularly if you’re getting paid for it. So, I picked psychiatry for my first elective rotation in med school, and saw what real mental illness is like. One of my patients was a teenage girl, who seemed outwardly normal, but confided in me that she had had an immaculate conception and was going to deliver the Lord’s baby. When I asked the attending psychiatrist if there was a pill for this, he looked at me like I was the crazy one. Psychiatry was definitely not my cup of tea.

Then, I looked into neurosurgery. As an undergraduate, I did an essay on a famous neurosurgeon named Harvey Cushing. An amazingly gifted physician whose written descriptions of his patients – complete with very accurate sketches – can be found to this day on display at Mass General Hospital. It would be great to have a career like Cushing, so I signed up for a neurosurgery rotation. But, this didn’t appeal to me either. The patients didn’t improve very often, and perhaps equally as important, I just couldn’t identify with the attending neurosurgeons who didn’t appear to be as interesting as I imagined Harvey Cushing to be.

So, like my daughter I applied for an internship in internal medicine. From an intellectual point of view, this seemed like a good fit, and I did identify with the attending physicians who seemed smart and articulate. But, there are so many specialties of internal medicine; I really wasn’t sure which to choose. Then, something happened. I was reading up on a patient with an unusual lung infection when I came across an article called “In Defense of the Lung” by a physician named Gareth Green. It described the complex interplay of factors that protect the lungs from infection, and how someday it might be possible to modify lung defenses to help susceptible people actually resist pneumonia. Something about this notion resonated with me, and for the next two decades the interface of infectious disease and pulmonary medicine was my career focus.

Some people find themselves in the career they always imagined for themselves, but I wonder if this is a good thing or not. Did they get a chance to explore how other career paths might have worked out? Were they willing to experiment and take a few chances along the way? As I say, I don’t know if this is a good thing or not. It may be much easier to pick something and stick to it, like my wife has. And in her case, it has been a remarkably rewarding approach. But, I can’t help wishing that my daughter would keep an open mind about opportunities that might come along in medicine or in surgery or in some other branch of medicine. Once this happens, then it could well be that something unexpected and great will be in store for her. I hope so.

Let’s Get Physical

In his great book “Cutting For Stone”, Abraham Verghese describes one of his main characters, Dr. Marion Stone, as being obsessed with a certain aspect of the physical exam.  Dr. Stone, as the dictatorial chief of surgery at a major Boston teaching hospital, has drilled into his residents the necessity of performing a rectal exam on every patient.  One intern forgets to do this, and is so terrified of his mentor’s wrath that he proceeds to chase the newly discharged patient out on the street and into a bar to do the deed.  On that particular night in the place where everybody knows your name, “bottoms up!” takes on a whole new meaning. In real life, Dr. Verghese teaches at the Stanford University School of Medicine, and is as devoted to the art of the physical examination as Dr. Stone is in the book.  In a New York Times article published two years ago entitled “Physician Revives a Dying Art: The Physical”, science writer Denise Grady rounds with Verghese and a group of third year medical students who are clearly impressed watching a master clinician point out the stigmata of liver disease and diagnose cerebellar ataxia without a CAT scan.

All medical students are taught to do a careful physical exam. When I was a student, we practiced on real patients. Now there are “standardized patients.” Trained actors are paid to report certain symptoms, and to say ouch when the student hits the right spot. Quite amazingly, there are ladies and gents who get paid to teach the finer points of the gynecologic and rectal exams (as one of my colleagues joked, “Here’s your paycheck ma’am, and would you like a psychiatric consult with that?”) In the fourth year of medical school, a test is administered nationally where students go from room to room encountering 10 or so such standardized patients, and are given 15 minutes to take a focused history, perform a specific aspect of the physical, and write up their findings. They must pass this test to graduate.  So what happens to our students between the time they finish medical school and when they become your family physician who spends 5 minutes with you typing on his or her laptop, “takes a listen” through your shirt, signs a stamped prescription for a Z-pack and sends you on your way?  Time pressures, limitless technology at our disposal, fear of malpractice and fewer opportunities for bedside teaching have all contributed to the demise of the detailed patient exam.

My chosen specialty of radiation oncology has become perhaps the most technology driven in all of medicine.  All of our treatment planning is done from a CAT scan—nearly all radiation therapy departments have their own scanners.  We are fairly low down on the food chain of medicine when it comes to making discoveries on a physical exam—by the time the patient sees us, with the notable exception of head and neck cancer patients whose tumors are best cured by a combination of chemotherapy and radiation, those tumors have been scraped off, whacked out, frozen, melted or otherwise assaulted.  Oftentimes there is nothing really to examine—I have mentioned before my mentor who said “Radiation works best when there’s no disease!”   Knowing that my CAT scanner is just around the corner, I sometimes feel a little silly doing a thorough physical exam.  So you can imagine my complete shock a few months ago when asked to examine a patient who had some very nonspecific complaints of fever and malaise on her first day of treatment, and to hear a big WHOOSH WHOOSH WHOOSH as I listened to her heart. I looked back at my initial physical—there had been no heart murmur two weeks earlier.  I sent her directly to the hospital, and 24 hours later she was in the OR having both her aortic and her mitral valves replaced for acute bacterial endocarditis, an infection of the heart valves brought on by an infected chemotherapy catheter.  I can only imagine the eye rolling that took place in the emergency room when the radiation oncologist called in a case of endocarditis—I mean they all know we’re the guys in the basement playing with computers and pushing buttons!  It was not the first time, but it was probably the most important time that my three years of internal medicine training had a huge payoff for the patient.  It saved her life.

In the NYT interview, Dr. Verghese said something else about the physical exam that struck me as an uncommon truth.  He said that a proper exam earns trust, and is the ritual that transforms two strangers into a doctor and a patient.  My daughter is interviewing for an internal medicine residency at Stanford next month.  If she ends up with Dr. Verghese as a mentor and teacher, she will be very fortunate indeed.