Doctors First, Specialists Second

One morning, I pulled an empty chart from the rack on the examination room door: new patient, Ms. Judith Cornish, age forty-seven. I knocked twice and entered.

“Good morning, I’m Dr. Shaw,” I flipped open the chart. “You are Ms. Cornish?” (I always used last names. It was formal, I know, but I preferred erring on the side of respect, not familiarity). I extended my hand. She sat, leaning forward in a chair, one very lean leg crossed over the other.

“Good morning. Yes, I’m Judy,” she said in a husky voice. She shook my hand half-heartedly.

In five seconds, I had processed a huge amount of diagnostic information:

One, her hand was cool. Most likely poor circulation from anxiety or smoking, less common causes certainly possible.

Two, she was thin, and sat with the familiar posture that we in medicine see frequently in undernourished alcoholics. (This may seem presumptuous, but experience is a good teacher.)

Three, her voice was raspy. High odds she was a heavy smoker (confirmed later by the smell of smoke on her clothes and by my questioning).

Four, her skin was pale and prematurely wrinkled for forty-seven. Again, cigarettes and alcohol likely.

Five, the dermatological diagnosis: psoriasis at least. (immediate telltale signs on her hands and scalp.)

Lastly, I could see in her face and body language that she was guarded, as if she wore a sign that said “EMOTIONALLY FRAGILE: HANDLE WITH CARE”. I would need to do just that.

“How can I help you?” I asked.

“You can help me with this!” she said, pulling up sleeves and pants to expose her elbows and knees which were covered with large areas of thick, scaly skin characteristic of psoriasis.

“How long has this been a problem?” I asked.

“A few months, maybe a year,” she said.

“Any treatments so far?”

“No.”

“Do you take any oral medications?” (Some common drugs can make psoriasis worse.)

“No.”

I asked her about other health problems—she had none that she knew of—and whether she had seen her family doctor recently—she hadn’t—and after some additional questions, finally arrived at the alcohol and cigarettes.

“About a pack a day,” she said. “And I have a few drinks every day.”

“Beer, wine?”

“Vodka, mostly.”

My preliminary diagnosis, which I didn’t share with her at first, was psoriasis with alcohol and tobacco abuse as contributing factors. I asked her to put on a gown, examined her and returned for the discussion after she dressed.

“You have a condition called psoriasis,” I said, and went on to explain the disease. “But what I am most worried about is your alcohol consumption. We know that cigarettes and alcohol make psoriasis worse, but my biggest concern is that you are drinking enough alcohol to threaten your general health and your life.”

Judy sat back in her chair, folded her arms and turned to the side. Her silence told me she was not pleased with the assessment.

I continued: “I’m going to treat you with these creams, but I encourage you to think about the alcohol and cut down or stop if you can. Your skin might improve on its own. Not everyone can do it alone; you might need help. I suggest that you talk to your primary care doctor, get your liver checked and have a physical examination. I’d like to see your progress in two or three months.”

“I’ll think about it,” she said. Her tone was indignant, and I didn’t expect her to follow my advice. I thought she might never return.

Judy did not return in three months, or in six months. It was not until a year later that I saw her again. I looked at the chart before entering the examination room and remembered our first encounter. This could be difficult, I thought.

“Well, hello,” I said.

She started right in: “Hi, Dr. Shaw. You know, I’m sorry for not coming back sooner, but I need to tell you something.”

I sat down without a word.

Her eyes moistened. “You saved my life.”

Surprised by her comment, I raised my eyebrows as if to say, “Is there more?”

She continued: “Remember last year when you told me about alcohol? I resented it at the time, and continued to drink—more, in fact—and my skin got worse. But I kept thinking about what you said, until it finally sunk in that you could be right. Anyway, I stopped drinking six months ago, and now I feel great and my skin is much better. I was sliding down a slippery path.”

I asked her if she’d stopped drinking on her own, and she sad that yes, she had. I told her that was wonderful, that she must be a strong-willed person and should feel proud of herself. She said she’d been drinking herself to death and didn’t know it.

“You were the only person who has ever been concerned about it,” she said. “I came in today to thank you.”

It is not often that a dermatologist hears the words “you saved my life.” Of course, it might not have been entirely true, but it was gratifying to know that my advice about a problem tangential to her immediate skin problem had influenced Ms. Cornish’s destructive lifestyle in a positive way. It made my whole day, my whole week.

In medicine, we don’t expect to receive praise for what we do, and successful treatments are often taken for granted by patients (as they should be, to a certain extent). To hear Judy’s appreciation was indeed special.

We went on to address her skin briefly, and at the end of the visit, I couldn’t help myself from saying, “Now, how about the smoking? Can you start thinking about cutting back or stopping?”

“That’s next, Dr. Shaw. I’m working on it,” she said.

We looked at each other. “One thing at a time,” we said in unison.

***********************

Take Home Message
The main teaching point is that if our goal is to be of assistance to patients, discussing behaviors relevant to their general health is important, even if it goes beyond the chief complaint. Don’t be limited by the chief complaint. The primary medical problem might be entirely different or even unrelated and should, at least, be acknowledged.  Also, the six points of information processing at the beginning are important learning points.

Author Bio
Dr. Shaw received his medical degree from Boston University in 1978, and after two years of internal medicine residency, he specialized in dermatology at the Oregon Health Sciences University. He remained in Portland until 1996 when he relocated to the University of Chicago. There, he became the head of the Division of Dermatology and the residency program director. In 2001, he joined the Faculty of Medicine at the University of Toronto. Presently, Dr. Shaw is Division Head of Dermatology at the Women’s College Hospital, University of Toronto, Canada.

Dr. Shaw’s academic interests include writing, teaching and clinical research. He is the recipient of several University-wide teaching awards. His areas of research interest include androgen-mediated cutaneous disease in women, and diseases of immunosuppression, especially organ transplant recipients. In 2005, he published the book The Quotable Robertson Davies, his first foray into literary publishing.  His second book, Room For Examination: More Than Skin Deep (2012) is the story of a medical career from the perspective of a dermatologist, student, patient, teacher, father, husband, researcher and administrator.  Author email: jc.shaw@utoronto.ca

Keywords: doctor-patient relationship, alcoholism, smoking, psoriasis, behaviors

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2 comments on “Doctors First, Specialists Second

  1. Brian T Maurer on said:

    Dr. Bell and A. Conan Doyle would have been proud.

  2. Yoon Cohen on said:

    Thank you for sharing this story. It offers a true inspiration to students and trainees including myself.

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