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In medical school they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter—she’s a nurse—made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. They kept me in a cell of one room for fifteen years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterwards I’d feel awful. They were right.
“I lost twenty pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure….”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for six-monthly skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. “The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot four years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this,” says. Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry too. Very sorry indeed. Like all doctors, I want to help. Sometimes I can help the skin, temper the presenting complaint. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
