“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.
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