"Do you think I need Botox?" Nora asks.
This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.
"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.
"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"
Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.
How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.
Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?
Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.
Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.
Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.
So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?
A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?
Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."
Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].