1. Starr, Barbara B.

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We never know who's going to be there when we walk in the exam room. Or what we'll learn, and what we'll need to teach.


I don't know what knowledge and experience and goodness of nature I'll have to draw on in order to help my patients. But I'm almost always glad they came, and tell them so.


The reasons for the visit begin to take shape. Sometimes we can easily see what our patient's problem is, and what the skin problem begets: fear, annoyance, lost sleep or work or social life, embarrassment, shame. Sometimes our patients give us a sense of who they are, what makes them tick; others remind us we can't begin to know what it means to be another person. I get to wondering, on my drive to work, "Who will I see today?"

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The Lincolnesque, deeply lined 75 year old with the 3 cm basal cell on his cheek laughed when I called him a "long, tall drink of water". I asked him about his work: "Hardtop." Laying asphalt. I thought of the steaming trucks, lumbering ahead of me, the tools iced with shiny black tar, the stink coming in my car window. I'd heard about the burns. He took a deep breath and sighed it out, shaking his head with a smile: "I[horizontal ellipsis]love[horizontal ellipsis]hardtop. Thirty-seven years. I just love hardtop."


We now talk about hardtop at his follow-ups. I have learned about the importance of the different layers that are laid down before the hardtop. He was visibly angry when I told him the technique used on my own driveway. He was offended on behalf of his field, the same way I would be if I heard about poor dermatology care.


I was sorely challenged the other day. The diagnosis was easy. Hidradenitis suppurativa. At 5'1", she weighed 270 pounds. I gently explained that one thing that could help was weight loss. She shook her head. "I don't think of my weight as a problem. I exercise, and I'm healthy." I got her permission to send a note to her doctor about her new diagnosis, and suggested she talk things over at her upcoming appointment. We worked out a plan for the acute problem. I offered to see her in a week, at the end of what I had wanted to be a short day, in the middle of a vacation. She couldn't come. No way: she was working at her hairdressing job. I thought, "I fit her in today and am willing to miss time with my kids next week, and she won't change her schedule." Then I really heard what she had said: She couldn't miss work, she couldn't let her clients down. I realized that this woman felt a similar commitment to her clients as mine to my patients.


We tell our patients that if our plan doesn't work, remember that this is just the beginning: There are many ways to treat their problem. We might have to adjust their regimen but we don't want them to come back in 2 years and tell us they stopped after 2 months because the medicine didn't work. Come back.


And likewise for you readers, with the Journal. One issue of the Journal might be closer to what you need than another. Come back. Report on our progress, and yours. What in the Journal worked for you and what didn't? What can you do to help? There are countless topics of concern in dermatology, for our patients and for us, thousands of diseases, and dozens of approaches for handling them. If one approach doesn't work, remember this is just the beginning. You readers and the Journal, as with you and your patients, have started a relationship that is going to be a fruitful one.


I'm glad you came.


Barbara B. Starr