Getting 'hands on'

Hi,

Last week was relatively quiet again, something I am getting dangerously used to on this rotation. I spend a couple of the days this week in dermatology clinics, where I got to get my hands surprisingly 'dirty' for someone with a week of dermatological experience, and one day in lectures. The other days I mostly had off. Working three and a half to four days out of seven is wonderful, don't get me wrong, but I think it is something I could quickly get used to, all these lovely lie ins and time to spend with friends. I think, after 6 weeks to get used to this, come a harder rotation, or my final year, I could get quite a serious shock to the system!

The clinics that I was placed in this week were both with the same dermatological consultant. They were much more interesting than the theatre list which I was in last week, and I was given a lot more to do.  The idea was that of the patients waiting, myself or the other medical student would pick the next to be seen, and take them from the waiting room to one of the examination/consultation rooms to take their history and examine the problem with their skin. We would then go back to the doctor, present what we had learnt about the patient and give our differential diagnoses for the condition and what we think should be done to manage the condition, then she would go to see the patient. She would look at the problem with the skin, exchange a few words with the patient to confirm the important things we had told her, and then decide on the course of treatment. This could be leaving it, putting a cream on it or cutting out out (which could be done then and there for most of the minor skin problems)

Because we two medical students were seeing different patients and doing much of the time consuming work (the history) this meant that the clinic could take place twice as fast, as she could just review the patients, carry out procedures such as cutting out parts of the skin, and do her paperwork as we talked to the patients. This made me feel useful, and was a great chance for me to practice taking a dermatological history. All aspects of medicine need different questions asked, and dermatology is no different, needing questions asked about things such as sun exposure which wouldn't factor into 'normal' histories. Because of being kept so busy at both of these clinics, the time flew by. This was a very different experience to the times I have spent in clinics in other rotations so far this year. The neurology and oncology clinics were very specialised, so the doctor would lead most of the discussion and I would sit passively in the corner for most of it trying my best to pay attention, learn something and not fall asleep. 

One of the clinics was for people who had been referred to the dermatologist under the two week wait rune, meaning that the GP who had referred them thought that the changes to their skin could have been cancerous, the other was just a general clinic for skin conditions. In both of these clinics I saw some pretty horrific looking skin problems, showing how important a cure is for a lot of these patients. Patients like those with psoriasis (picture below) can have their lives turned around if it is treated properly. Unfortunately the dermatology clinic encourages us not to use gloves unless the wound is obviously infected and oozing, as using gloves gives patients the  impression that they are dirty and unclean, an idea that we are trying to dispel. While this may be good for the patient, it certainly isn't good for the medical student as you try and rummage through peeling skin to look at the sore underneath to see if it has a 'pearly looking edge' to differentiate a basal cell carcinoma from an area of actinic keratosis.

Psoriasis across a ladies back. This is an auto-immune condition where the skin becomes thick, scaly and peels

In summery, while the week was pretty relaxed, the time I did spend in the hospital was very productive. I now feel a lot more confident taking a dermatologically skewed history and examining damaged skin to try and spot cancers. While I still don't think that this is the speciality for me, the fact that I have only seen about 5 conditions so far makes it easy for the medical student to clerk the patient in and guess at the problem. I am enjoying this rotation a lot more than I was last week, and I hope that this continues!