After retirement, a visit to a dermatology office

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!

Miranda Fielding is a radiation oncologist who blogs at The Crab Diaries.

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  • querywoman

    I am a chronic dermatology patient. My current derm is a treating, teaching, and research doctor with a few other derms in his office and a PA.
    Then, there are a bunch of residents.
    They are always very busy. His priority is sick people, not the cosmetic procedures. Of course, all dermatologists who treat acne are cosmetic doctors too.
    I know he’s trying to educate the world and advocate for his precious patients.
    It would be so nice if the non-dermatologists would try and learn more about skin disease!

    • Miranda Fielding

      I agree with you. As a radiation oncologist, I treated a lot of basal cell and squamous cell skin cancers in my regular practice, but I also treated rare cancers involving the skin such as Merkel cell tumors and cutaneous lymphomas. I don’t recall a lot of time in medical school or in my internal medicine residency being devoted to chronic dermatologic diseases or cutaneous manifestations of systemic cancers. More attention to these problems can avoid misdiagnosis of potentially life threatening conditions.

      • querywoman

        Keep at it! You indicate you are semi-retired? I have faith in you to be a trailblazer!
        I can’t believe how many doctors claim they can’t do a simple skin biopsy on my arm!!! Yet, they can do a Pap smear?
        We don’t need to discuss my own needs. Just see it as a need for you to advocate for patients with skin disease.
        I have had atopic eczema, getting decent treatment, for about 6 years. It’s slowly flaking off. Frustrated, but getting better.
        I am currently undergoing some unna boot bandaging treatment with clobetasol on my legs that’s getting me much better. However, my eczema flakes are hard, dry, and cut into me. I am at serious risk for infection when it gets thinner. Don’t worry, I am being monitored.
        Perhaps I will make private contact with you.

        • kidmodel

          dermazinc or dermazinc plus alternating with something like Sarna……

          • querywoman

            I need more than Sarna. I just got some Silvadene, which seems to work very well for me. I am currently getting unna boot treatments for my legs. I’m in my 3rd weekly one. We put the steroid on my lesions, then wrap my legs with unna boot tape that has zinc oxide, and put Coban athletic bandaging on them.

            It relieves the pain instantly.

          • querywoman

            Silver sulfadiazine is working quite well for me now. A nurse practitioner prescribed it for me. I won’t go into it, but I’m not even sure she has a license. I’m looking into that now.
            She told me to tell my derm about it, and I did. I saw him briefly a couple of days ago when a nurse got him to look at me coming out of bandaging, and he and I both liked the effect of it me. So I will keep using it for two weeks, and then have a full appointment with him.
            I’m not upset that he didn’t think about it for me, either. He’s glad it’s working, and so am I!

      • querywoman

        I reread the article and see you are basically treating skin cancers. I do hope you will get more exposure to stuff like eczema and psoriasis.
        Cancer gets drastic treatments, which may or may not prolong and improve the quality of life.
        Most skin disease is chronic and has to be managed.
        Very different type of medicine!

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