Internal Medicine Reflections

For one month this spring, I rotated through Dermatology. Perhaps because the specialty is visible and tactile in such an intimate way, the stark reality of what we sometimes do to our patients – not just for our patients – became very apparent to me.

One memory that has stayed with me involved an elderly gentleman from a nursing home. Thin, frail, and unsteady, he arrived with a past medical history significant for skin cancer, status post a Mohs surgery that resulted in the partial resection of his jaw. Per protocol, he was here for a routine skin check. I talked with him, then started to examine him, head to toe. His hair was thin, light, and fine like that of a baby’s. His face and ears were speckled with small hypopigmented scars, an attestation to a lifetime of cancerous and precancerous lesions, removed by cryotherapy or biopsy. But what was most striking was the left side of his face, where the angle of his jaw was removed. The skin sagged over a wide concavity, as if that area of his head had been punched in, like in some silly cartoon. He wasn’t just physically fragile from age and wear. He was emotionally fragile.

To all questions, he replied with a timid “okay”, as if he were a child, and as if agreeing was the right answer. “Sir, is it okay if we biopsy this small area? We’re afraid that it might be a small basal cell.” “Oh, okay.” We finished the exam, and we finished the small biopsy that we had decided to perform. Then, as the clinic was about the close, we simply said, “You’re all set now. You can go whenever you’re ready.” And we left him to slowly change back into his clothes and leave the clinic, all alone.

Comparable examples can be found in other fields of medicine after extended hospital stays, rounds of chemotherapy, or just an energy-sapping bout of pneumonia. Whether it is a result of the disease, the treatment, or the accompanying immobility, patients are often left to face extended periods of rehabilitation and/or scars to remind them everyday of what has happened. Worse, the debilitation and the scars remind them that they can no longer function as they once did, that they are no longer perfect. As physicians, we try to patch these patients back up with plastic surgery, supplements, or even just more pills. However, in the case of Dermatology in particular, completely scar-free procedures are impossible, and scar-minimizing procedures are often too expensive.

Ironically, the fear of having to undergo the same treatments again may very well be what keeps the patients coming back to us. In return, we as physicians decrease the risk of further disease, but without absolute guarantees. Particularly for those patients without strong support networks, this vicious cycle results in a willing, but heartbreakingly self-defeated relinquishment of patient autonomy.

I am not sure of how to break this cycle. The treatments we offer are generally necessary and good. For my patient, he likely would have ended up with an aggressively invasive – if not metastatic – cancer if he had foregone that initial surgery. On the other hand, physicians are not gods. When clinics are overbooked, and the end of the workday is approaching, our most immediate thought is often to prioritize the necessities and then move on to the next patient. However, perhaps we can lessen the hurt and give those emotionally beaten patients a sense of dignity and control by spending that extra minute or two to talk with them about themselves. Our patients need to know that their physical imperfections do not make them imperfect human beings, and we need to affirm their lives by showing them that they are important and worth our time.


Nan Guo is currently an in-betweener doing a research fellowship between her MS3 and MS4 years. She learned quickly during 3rd year that she could basically write whatever she wanted – however she wanted – for these reflections essays, and the only person she needed to impress was herself. Thus, she started to write these essays as notes-to-self. The purpose of this particular piece is to remember the importance of preserving patient dignity and self-worth, along with the incredible heartbreak that can result otherwise.