The patient: Mary, a woman now in her mid-40s with a 19-year-old daughter, initially came to me when she was her daughter’s age. They both continue with me as one of their primary care physicians.
Why she came to see me: Mary was transitioning from seeing her childhood pediatrician to seeing a generalist. She came to me because she felt that by assessing her diet and lifestyle and considering nutritional supplementation, she could feel better and stay healthier.
How I evaluated her: Mary initially came in with a copy of routine blood work and discussed the care she had received from her general practitioner. I explained to her that typical physical examinations were often either cursory or missed important concerns, and that in my practice after med school with Robert Atkins in Manhattan, I had developed a relatively quick exam that sometimes caught things that might have been missed.
One of the questions I have always found useful is, “Are there any interesting features on or under the skin, like bumps or lumps or discolorations, that have not been discussed or examined.” She mentioned that she had noticed a “little mole” on the back of her right knee that she discovered a few months ago while putting on stockings. I looked closely at this relatively innocent-looking feature under magnification and asked her if it had changed in any way. She reported that recently it had started to itch.
I told Mary that although the mole appeared superficially like a noncancerous “pigmented nevus,” the itching she reported and the somewhat irregular border surrounding the lesion concerned me.
How we addressed her problem: When I set up my practice in Southbury, I initially worked in a medical center and shared office space with a somewhat cantankerous-but-brilliant Yale-trained dermatologist for whom I had great respect. I explained to Mary that dermatology was one of those specialties that requires deep dedication and that the differential diagnosis of her little mole required the sort of “seasoned eye and clinical acumen” that only years of focal practice produced. I called over to the dermatologist’s office and had her seen the next day.
Mary and I recounted the call that I received a few weeks later after he removed the mole and had it biopsied. In his thick accent, consistent with his Middle-Eastern heritage, he succinctly stated, “Rubman, you probably saved this woman’s life. The lesion was an aggressive melanoma and if not removed would have killed her within a year.”
The patient’s progress: As you know from the beginning of this story, Mary is living a full, rich life.
So the takeaway for everyone, not only for Mary, is to remember (1) that any one doctor can’t know everything and (2) that preconceived notions (here, that the incidence of melanoma in teens is quite low) may blind one to a real problem. I try to remind my MD colleagues that they should know when to refer to me, as I try to remember when to refer to them.