“Neither kernel nor shell: nature is both in one …”
Goethe
 
As I edited a paper recently for Global Family Doctor on the relationship of the psyche and the skin (a very poor study, I thought: http://www.globalfamilydoctor.com/search/GFDSearch.asp?itemNum=10440), I was reminded of Goethe’s quote (above) and how important concerns of members of the public are with regard to dermatological problems.
 
The GFD Medical Editor’s recent blog on “two Fs of Politics” further reminded me of my eleven Cs of Dermatology.
 
I have decided to share them in my first GFD blog.
 
I recall listing, in the early 80s, four patient concerns related to skin problems co-incidentally starting with the letter “c” in the English language.
 
This gradually grew to seven, which for many years, as a group, had their own glass ceiling due to calling them “the 7 Cs” based on the concept of “the seven seas”.
 
Once I broke the barrier with an eighth, recently, I felt liberated and reached ten Cs of Dermatology, which had their own glass ceiling, until I added an eleventh: eleven potential items of concern to patients with dermatological conditions, for a general practitioner to also consider a patient / parent / partner etc may have, even if not stated, namely (in no particular order):
 
Contagiousness (self and others) 
Cancer 
Congenital / genetics 
Cosmetic look and outcome 
Cause 
Course (including control / cure / clearing) 
Cleanliness 
Comfort 
Cost 
Complications of treatment 
Co-morbidity
 
These concerns have been listed based on comments such as:
 
Cleanliness: I see this concern frequently (eg ‘cradle cap’, scabies, impetigo) and also in other areas of medicine eg thrush, conjunctivitis (“What will others think?”)
 
Contagiousness (self and others): related to cleanliness, but with a further hint of blame / guilt
 
Cancer: frequently underlying concern, especially melanoma
 
Congenital / genetics: again, with a hint of blame / guilt
 
Cosmetic look and outcome: people can be socially and / or sexually incapacitated with eg acne, keratosis pilaris, pityriasis rosea
 
Cause: further hints of blame/ guilt. Frequently leads to internet searches and downloads. Can also lead to self harm eg delusional parasitosis
 
Course (including control / cure / clearing): include fears of having ‘it’ for life, or beliefs ‘it’ is over if cleared
 
Comfort: concerns re pain, discomfort etc eg herpes zoster, pruritus
 
Cost: costs of consultations and treatments can be a real problem and may be outside the patient’s control eg acne
 
Complications of treatment: eg fear of topical steroids
 
Co-morbidity: patients may not see the problem as beyond the skin eg acanthosis nigricans and may not be motivated to change, undergo investigations etc.
 
Predicting, eliciting, pre-empting the eleven Cs with explanations and adequately dealing with them can be a great source of satisfaction for patients, families / partners and the general practitioner.
 
Some of these concerns can even be discovered proactively (discrete questions / comments eg As a doctor, I noticed as I was up close that you have some acne / facial hairs / bumps on the outer part of your upper arms / thinning of your hair ….which can be accompanied by another helpful question ….  is this / are these lesions / this rash of any concern to you?) and, if the GP is unsure how to manage the condition or concern that is brought to light, it may be a reason for referral to a dermatologist.
 
Now that I am liberated, I welcome a twelfth (the dozen concerns may have their own glass ceiling, as may a baker’s dozen) or beyond!
 
I love teaching dermatology to GP registrars and hope to reclaim much of dermatology for general practice / primary care. Dermatologists are not our competition, they are out allies / colleagues … in Australia, the enemy is the girl in the white uniform in the pharmacy who promotes frequently incorrect or inefficacious topical therapies or items which lead people to great costs, or the network marketing equivalent, so that people are not willing to spend further on what we recommend, or to nihilism about therapies we have available.
 
Please share your thoughts and also suggestions re more Cs in Dermatology.

Recently overheard: “Oh, I never get the flu shot – I always get the flu from it!”

Also recently overheard: “I want to be careful about shaking hands – I might get swine flu!”

“Swine” flu has certainly got our attention! As schools go back in session for the fall (in this part of the world…), pandemic planning is kicking into high gear with contingency plans for school and work absences, plans for the H1N1 vaccine, and posters seemingly everywhere advising precautions to limit the spread of H1N1.

All this planning certainly makes sense, and represents, I think, a great example of coordination among different sectors of the public health community.

But do we really need to stop shaking hands?

Seasonal influenza has been with us for years – and people still mistake “flu” for vomiting and diarrhea (at least in our area!), still avoid the flu shot thinking it will give them the “flu,” and we still have unacceptably low uptake of flu shots in both the general population and among health-care workers.

Novel H1N1 seems to have people even more worried than they were with SARS (or moreso!), yet precautions for seasonal flu still get brushed off.

How to respond?

It’s easy enough to be irritated when people brush off longstanding health threats – while novel threats get all the attention and generate lots of worry. But the family doctor in me has to wonder, “Why?”

• What is it about human nature that makes the new and different seem so exciting or threatening, and the old seem blasé and routine?

• What is it about my communication with my patients that has us (my patient and me) STILL meaning different things when we talk about the “flu”?

• How do I respond to the patient who I think is mistakenly taking the “it can’t happen to me” view?

• How can I focus the worry about the “new” into energy to deal better with the “familiar?”

Swine flu is new – but new infectious outbreaks are not. SARS, a local Norovirus outbreak, community-acquired MRSA, etc, etc, etc.

Each new threat is vital to address, but maybe each new threat may help us as docs find ways to  understand our patients better and find those “teachable moments” we’ve been looking for – to help motivate change in dealing with the familiar.

Seasonal flu and swine flu. How can our response to one help us respond better to the other? And how can our patient’s responses to BOTH help us understand our patients better?

Over that last year Global Family Doctor has reported several studies showing that higher fat content in diets is healthy. The latest one this week by Esposito et al showed that newly diagnosed diabetics who were instructed to follow a Mediterranean diet with 40% fat content had better blood sugar control, better cholesterol reduction, less use of oral hypoglycemic medicines, and more weight loss that those instructed to follow a standard diabetic diet.

In June 2009 we reported the study by Jenkins et al showing that a diet high in plant-based fat lowered cholesterol. A systematic review by Mente et al that we reported in April showed benefit of Mediterranean diet and intake of fish oils for prevention of heart disease. In January we reported a study by Salas-Salvado et al in which Mediterranean diet plus 30 g daily of mixed nuts decreased the risk among people with metabolic syndrome to advance to diabetes type 2 compared with Mediterranean diet alone.

It seems like time to abandon low fat diets and recommend good fat diets instead.