Abstract:  A young dermatologist discovers that treating the patient may entail more than just examining his skin.  Sometimes, it is more important to treat the person than address the “chief complaint.”

Keywords:  doctor-patient relationship, aneurysm, skin exam,

IT’s a busy morning at the clinic. My next patient is a 62-year-old man. After some small talk, he quickly turns to the point of his visit: evaluation of suspicious skin lesions on his back.

“I’m only here because my wife’s concerned about these two spots.  Otherwise, I feel fine.”

He seems to be in a hurry, so I quickly examine his back and find only benign keratoses. When I offer to do a complete skin exam, he shoots me down. “Eh…I’m fine. My last physical was 20 years ago when applied for life insurance. I don’t have anything I’m worried about.”

Noting his well-tanned skin and light skin type, I ask, “Does anyone in your family have a history of skin cancer?”

“No,” he says, “but we’ve got a history of aneurysms. My mother had one. One of my sisters died from a ruptured berry aneurysm, and another sister was just diagnosed with one as well.”

My ears prick up at this news.

I take his blood pressure: 182/120.  Just to be sure, I repeat it and get the same reading.  Hesitantly, I inform him. “Your blood pressure is high. Who is your primary care doctor?”

“I haven’t got one.”

“We’re concerned about your high blood pressure and the strong history of aneurysm in your family,” I explain. “We suggest that you make an appointment with a primary care doctor for further evaluation. We can recommend a good doctor if you want.”

Now he’s more concerned and quickly agrees.

I awake the next morning with this patient in my thoughts, consumed with “what if” scenarios. What if he has a stroke next month; what if an aortic aneurysm ruptures next week; what if he dies from a berry aneurysm tomorrow?

When I call his home to remind him of the importance of following up with a primary care doctor, I get a voice message instead. Because of HIPPA rules, I can’t leave detailed information about his health on the answering machine.

A few days later the man’s wife calls the office.  She sounds suspicious; even her words seem accusatory. “I know you called with concerns about my husband’s blood pressure.  Are you sure it’s that high? No mistake?”

She talks nonstop without giving me a chance to respond. I imagine that she’s frightened by this unexpected information about her husband’s health. Despite her questions, I inform her that I can not discuss her husband’s health information without his consent. Understandably, she’s frustrated. She tells me that she will have her husband give me a call.

Several more days go by with no return phone calls. I feel uneasy about placing another call to the home, and yet I feel the need to follow up. I elect to send a letter to the patient, gently reiterating my concerns:

Dear Mr. Johnson (not his real name),

We have tried to telephone you a few times; however, due to HIPPA rules we were not able to leave a detailed message.
Although your skin lesions were benign, the family history of aneurysm prompted us to check your blood pressure.  The readings were high, and the fact that you don’t have a family doctor led us to recommend that you see a generalist (internist, family physician) to get this properly evaluated.
We don’t want you to worry unnecessarily.  At the same time, we don’t want to ignore a possible health risk.
We will be happy to talk to you about this or facilitate an appointment with an appropriate generalist.  Please let us know if we can be of service.

Another week goes by, and I hear nothing from the patient. I had hoped that he might have scheduled a proper evaluation with a primary physician. Not getting back to me was not an issue, as long as I knew that he would help himself and ultimately his family.

Today, after seeing a patient for a procedure, I learn from one of our staff members that there is a surprising but good message waiting for me at the front desk. With a curious look I find a piece of paper with this brief note:

A message for Dr. ___:  “Mr. Johnson called to thank you for taking his blood pressure and insisting that he get treatment. He says ‘Thanks’ for pushing him or he would have let it go. He is now on medication for his high blood pressure.”

A patient’s visit is a window of opportunity. In this case my patient had no concerning skin lesions; however, he may have been here for another reason.  Although he implied that he had made the appointment just to humor his wife, revealing his family history might have been a cry for help. One probably would not expect to hear about a potential aneurysm at a dermatology appointment; however, as physicians, we have a duty to try to help our patients with other problems as well.

As dermatologists, we are care-givers first, specialists second; we strive to treat the whole patient, not just their skin disorders.

Acknowledgement:  Sincere thanks to Brian Maurer for his gentle and expert editing.

Yoon Cohen, D.O., is a resident at Alta Dermatology in Mesa, Arizona.  A native of South Korea, she did her medical school at the University of New England in Biddeford, Maine.