Under My Skin

Last Case


Dear Intern:

Well, your elective is over. So is medical school, since this is your last rotation. I get nostalgic this time of year, having graduated 40 years ago, which I’m sure you’ll agree is a ridiculously long time. Because you matched at your first choice, you are now well and truly launched.

One of my recurring sentimental notions is to note a student’s last case in medical school. Will this encounter be noteworthy; or will the whole thing end, so to speak, not with a bang but a whimper?

Looking for significance in a last case is similar to quoting people’s last words. The famous ones you hear about are usually edited, interpolated from some earlier occasion, or made up altogether. If you’ve seen people breathe their last, you know that most are not able to say much of anything, nor are their families, should they happen to be there, in any frame of mind to absorb enduring wisdom.

But lo and behold – our last encounter together on this elective has indeed turned out to be unusual, perhaps even memorable. We should discuss it.

A biopsy report just came back via fax, with the heading, "Crucial Clinical Information." We saw this patient together yesterday. Truong was the Vietnamese man in his mid-20s. A mole on his back started to grow. It got itchy, he said. It bled twice.

We examined the mole in question, along with the rest of him. As you recall, he had several moles, all black like the one in question. The irritated one was regular in outline, except for a scab in the center, consistent with having been scratched.

You remember that I was not very concerned. I said that raised moles often worry patients but aren’t usually a problem. Bleeding, moreover, is mostly a sign of minor, unrecalled trauma, a scratch while sleeping or something like that. As you’ve seen this month, patients troop in daily to complain that this mole is itchy or that one has bled. I often take these lesions off to reduce anxiety as to make the diagnosis. As a prospective primary physician, you will have to make judgments about itchy moles all the time.

I asked Truong how much the irritation bothered him. He waffled. I did the biopsy.

Here is the report: malignant melanoma, level IV, thickness at least 2.1 mm.

This is what runs through my head as I read this: At this point in my career, I am as good at judging moles as I am ever going to be. I am as clinically astute as I am ever going to be. And yet, here I am, still managing to almost miss a diagnosis in which the patient’s well-being, even his life, depends on my getting it right. In how many other cases have I (and the patient) not been so lucky? How would I know?

What lessons can I draw from this experience, and which ones can I pass on to you at your very different stage of clinical life? That because certainty is unattainable, we should take off every mole just to be sure? Every mole a patient points to? If we did that, would we be better doctors? Would we be treating patients, or our own insecurity?

It has always seemed to me that in medical practice and, in general, it is best to avoid the extremes, to be neither cavalier nor paranoid. Every passerby may assault you, every neighbor (or patient) may sue you, but it’s no good going through life treating everybody as a potential mugger or litigant. You won’t have many friends if you do that, and your patients will have a lot of unnecessary scars on their skin.

There really is something to the old saying: smart is good, lucky is better. Difficult or atypical cases can make the clever and diligent doctor look like a fool, or worse.

So perhaps your last case in medical school will come to mind from time to time as your career advances. Work hard, study hard, pay attention; become as good as you possibly can. But don’t ever get too comfortable. We try our best, but nobody always gets it right.

Good luck!

To respond to this column, e-mail Dr. Rockoff at our editorial offices at [email protected].

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