Many years ago, when I was still in primary care (internal medicine), I thought I knew a bit about the practice of medicine. I was totally comfortable in the hospital (in those days, we saw our own patients twice a day in the hospital), including the ER, the OR, even obstetrics. MIs, shootings, stab wounds, renal failure—I would never say I had mastered them, but I was comfortable with most of what I saw. Deliveries, assisting with C-sections, performing lumbar punctures, performing and interpreting exercise tolerance tests, performing flexible sigmoidoscopies—no problem.
But the one thing that nearly always stopped me in my tracks was … you guessed it: dermatology complaints. Rashes, lesions, or any other skin complaint the least bit out of the ordinary were completely baffling to me. I still remember that feeling after all these years (and I still occasionally experience it!).
I felt like saying to those patients: What in the world would make you think I’d have any idea what that is? But of course, I couldn’t say that, so I’d mumble something, throw some cream at it, then quickly change the subject. Mind you, this was in a setting where a derm referral from us would take 4 to 6 months. And in case you’re wondering, the other providers in my department were as bad at derm as I was.
Long story short, it got to the point that I would scan my schedule every morning, praying I wouldn’t see the word “rash” or “skin.” But, of course, they still came—often just as my hand touched the doorknob to leave: “Oh, by the way, what about this …?” You get the picture. Many of you, if not most, live that picture.
I finally got up the nerve to go to our dermatology department to ask if I could follow one of the docs while he saw patients. Little did I know that practically every provider in the building had already done the same, and had been dismissed with words that essentially meant, “You? A mere PA? You can’t get there from here. Just send ’em to us.”
For a short time, I bought that line—but in the meantime, my patients were not getting the care they needed. So, driven in part by anger at the notion that a mere PA was simply unable to learn dermatology, I bought a decent textbook, Fitzpatrick’s Color Atlas of Dermatology, and started reading it. I also started collecting all the derm articles I could find in the journals, and read about those cases.
And a funny thing happened: The more I read, the more diagnoses I recognized on my patients. My colleagues and the clinic schedulers took note of this and began sending me their problem cases. Even the derm department, beleaguered as usual by huge backlogs of patients, started sending patients to me. By 1985, even though I was in the internal medicine department, I had transitioned to doing derm fulltime. And that’s what I’ve been doing since.
Around 1992, I discovered that I was one of 6 dermatology PAs in this country. Last time I checked, our numbers were approaching 4,000. So, yes, derm is indeed difficult, but rocket science it isn’t.
Being the pedantic sort that I am, and finding that whole experience so enlightening, I resolved to make it my mission to foster the use of PAs in dermatology—part of which involves the education of those PAs, by means of taking students but also by writing articles (several hundred at last count) and lecturing at conferences and at PA programs. Nearing retirement, I only practice two days a week, but I write and publish at least 5 clinical articles a month, all of which are based on real cases: my cases, using my photos, doing new research on each case. This keeps my knowledge fresh and my 75-year-old mind sharp, helps ward off burnout, and, most importantly, saves lives while reducing patient discomfort.
What follows are 10 dermatology pearls that I have gleaned along the way. My apologies to my former students and attendees at my lectures who’ve heard all this before:
1 If the treatment for your diagnosis isn’t working, consider another diagnosis. Here’s an example (Figure 1): A man in his 50s was sent to dermatology for psoriasis that wasn’t responding to a biologic. Was it really psoriasis? A KOH prep quickly showed it to be tinea corporis, which cleared completely with a month’s worth of oral terbinafine (250 mg qid).