Taking a dermatological history

FigureMy friend, a colleague and medical mentor, and I are sitting at a table in a small café, catching up with one another. It's been nearly a year since last we've sat face-to-face. We order an appetizer of focaccia, which comes in portions large enough to trim our hunger. The waitress suggests that we consider sharing an entrée and points out the deluxe burger. “It's a good size and comes with a generous side of fries. You can split it on two plates—no extra charge.” She retreats to the kitchen to place our order. “She's pleasantly attentive,” my friend says. I nod my head. “Nice tableside manner, too.” Our talk turns to patient care. My colleague, now into his eighth decade, is still practicing clinical dermatology four mornings a week. “My wife says it's become my hobby now,” he says with a smile. “Any interesting patients lately?” “Let me think.... Last month I saw a 62-year-old woman for the first time,” he says. “She self-referred for a consultation about her recurrent cold sores. She'd suffered with them for years, been to any number of doctors, but hadn't had any satisfactory response to treatments.” “What did you offer her: antiviral suppressive therapy?” “Not initially. I just asked her to tell me a bit about herself. She's an elementary school teacher in a small town in the county. She's got nine students, all of whom have severe behavioral issues. They're a handful. I gathered that she doesn't get much administrative support. She's had to bear the brunt of some physical abuse from a couple of the bigger kids.” “That sounds like a pretty stressful situation.” My friend nods his head. “She'd like to retire, but she can't. She's the sole wage earner for the household. Her husband's got bipolar disorder and hasn't worked for years. Periodically, he stops taking his meds, gets verbally abusive with her, complains that she doesn't keep up the house.” “She's getting it from both sides: work and home.” My friend takes a drink from his water glass. “Then there's her parents. Both in their late eighties, both need some degree of care. Her father has dementia, her mother's got a list of chronic ailments.” “Wow,” I say. “I assume they're in some sort of assisted living situation.” “She cares for them in her home.” I drop my eyes and shake my head. “Unbelievable—no wonder she's stressed.” “Yes. She told me that none of the other doctors that she's seen over the years asked her any questions about anything other than the cold sores.” “I guess with the corporate takeover of medicine and private equity, few clinicians have the luxury of exploring psychosocial issues in 10-minute visits,” I say. “Lucky for your patient, your practice has morphed into a mere hobby.” Our waitress arrives with two plates, each filled with half of a massive burger on a roll and mounds of French fries with ketchup on the side. She slips a plate in front of each one of us with a smile. “How's that?” she says. “Excellent,” I say. “Great suggestion—thanks.” I dip the end of a French fry into the ketchup and raise it to my mouth. “So tell me: what happened with your patient?” “I suggested a suppressive regimen with one of the antivirals. I just saw her this past week. So far she hasn't had another outbreak—there's always that possibility, of course—but overall, she seemed to be better, a lot more at ease.” “I've always been amazed at how effective just validating another's suffering can be to help them heal,” I say. We set ourselves to devouring the food on our plates and sit back, satisfied. Our waitress returns. “Anything else?” she asks. “Just one thing,” I say, pulling my smartphone from my pocket. “Would you take a photo of the two of us? We only get to see each other maybe once a year these days.” The waitress accepts the phone and steps back. “Smile!” she grins. “I took two, just for a backup.” “Thank you.” She clears the plates from the table and retreats to the kitchen. “You know,” I say to my friend, colleague, and mentor, “somehow I get the feeling that our waitress would have made a first-rate clinician.” My friend nods; we raise our water glasses and toast her with a clink.