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A building must shelter us from the rain and not fall down, but to be considered architecture, it needs to do more. Architecture critic Paul Goldberger, in his recent book, "Why Architecture Matters," explores what makes a building architecture, rather than just a roof over our heads (Goldberger, 2009). This got me thinking about dermatology and the patient visit: what is the difference between an adequate patient visit and one that rises to a different level? How do we achieve the level of architecture in the exam room?


"You could say that architecture is what happens when people build with an awareness that they are doing something that reaches at least a little bit beyond the practical. It may be as tiny a gesture as painting the front door of a house red or as grand an undertaking as creating the rose window of a cathedral" (Goldberger, 2009).

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Like a building (but unlike a symphony), a dermatology office visit must fulfill a practical function. The primary obligation we have to our patients is to make the correct diagnosis and choose appropriate treatment, to make sure that they get better, and help them if they can't. The office visit, and the care we take of our patients, would not be considered adequate if we didn't do that.


Several features distinguish the office visit that merely keeps the rain off, from one with at least a red door, if not a stained glass window. One is knowledge, knowing dermatology; not just looking closely at the skin but knowing what to look for, and what it means. This also includes knowing the best set-up for a surgical tray, how to expertly assist in Mohs surgery or with a laser treatment, how to bandage difficult sites. It includes knowing what to ask a potential phototherapy patient, and when to hold a dose or skip a treatment. (You are contributing to your knowledge of dermatology right now, by choosing to read this journal.)


Another feature that should be present is taking the time, and caring enough, to apply one's knowledge. Just as a building has an obligation to protect and enclose, it is our obligation to think. What we have learned is only valuable to our patients if we apply it.


What else makes a patient visit reach beyond adequate? We could talk about cultural sensitivity. We could cite the importance of speaking to older patients with respect, not in high, sing-song voices; talking directly to the 92-year-old patient in the wheel chair, not just to her daughter. Reaching the next level means listening to the patients as they describe what has happened to their skin. This is important: the changes they have noticed are strange and fascinating to them-sometimes it has been the patient's and their family's primary focus for days. We need to make sure the patient knows that we know that their hair used to be thick; that their skin used to be the envy of their peers.


By listening, by empathizing and educating, by our commitment to learning dermatology, and by assiduously bringing that knowledge to bear, we show respect for our patients. We lift stones and search for clues, ask questions and consult with colleagues. We look up information, call the dermatopathologist to discuss results, attend conferences, and read journals. We recognize and respect the humanity in that little room. The patient's humanity, mostly, but our really working to address their problem-the hard work that we continue to devote to our study of this beautiful specialty, the hard work of recognizing when we need help, and of listening to and pulling for these sometimes very difficult, unhappy patients-reveals our own.[black small square]


Barbara B. Starr






Goldberger, P. (2009). Why Architecture Matters (p. ix). New Haven: Yale University Press. [Context Link]