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HEALTHCARE LAW

Melanoma Makes Me a Real Doctor

By John “Lucky” Meisenheimer, MD and John Meisenheimer, VII

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When I was in medical school and revealed to my classmates that I wanted to be a dermatologist, they usually gave me a flabbergasted look and said, “You want to pop zits for a living?” Immediately followed by, “You don’t want to be a real doctor?” I wish the Seinfeld episode, when Jerry was dating a dermatologist, had been released so that I could refer them to it. The Seinfeld episode went something like this:

Jerry was having dinner at a restaurant with his dermatologist girlfriend.

Seinfield - “How’s the life-saving business?

Dermatologist girlfriend - “It’s fine.”

Seinfield - “It must take a really, really big zit to kill a man.”

Dermatologist girlfriend - “What is with you?”

Seinfield - “You called yourself lifesaver. I call you pimple popper M.D.”

A restaurant patron walks up to their table and says, “Dr. Sitarides?”

Dermatologist girlfriend - “Mr. Perry, how are you?”

Mr. Perry - “I just want to thank you again for saving my life.”

Seinfield - “She saved your life?” Jerry has a shocked look on his face.

Mr. Perry - “I had skin cancer.”

Seinfield - “Skin cancer, damn.” Jerry’s face twists in the agony of defeat.

As a Mohs surgeon, I rarely “pop” pimples anymore, not that there is anything disgraceful about helping a patient with a disfiguring skin disease that can leave them permanently scarred. As the Seinfield episode would suggest, laypeople might seem to think unless you are saving lives, you are not a “real” doctor. So, I guess in a sense, melanomas make dermatologists “real” doctors (and let’s not forget squamous cell carcinomas and basal cell carcinomas can also kill you). I know in my practice over the last 30 years, I have found hundreds of melanomas. Even to this day, when I see a melanoma, I quietly give myself a high five. When you catch melanoma in time, you have changed a person’s life for the better, even if they may not realize it. At the same time, I am also grateful that I did not miss that melanoma. There is always a degree of stress when doing a “routine skin exam” there is nothing routine about melanoma or the potential for missing a melanoma.

Melanomas come in all different shapes and sizes. They are rarely the archetypal jet black, nodular mole-like growth, in which even a first-year medical student could make the diagnosis. Melanomas may appear elevated, they can be flat, they can be multicolored, and they do not have to have pigment. Some melanomas can persist for very long periods before being discovered, such as lentigo maligna melanoma. Others can grow rapidly and deadly in a few weeks. Melanomas can develop beneath the nails, and even in non-skin areas such as the eye, oral cavity, nasal sinuses, even rectally.

The best guidance for identifying melanomas for non-dermatologists is using the mnemonic ABCDEs of melanoma evaluation, Asymmetry of the lesion, Border irregularity, Color variation, Diameter greater than 6mm and Evolution. However, dermatologists rarely use the ABCDE guide, as most of us know by looking because of intuitive expertise. When a dermatologist observes a suspicious lesion, in our mind, it pops up, “that looks suspicious.” Intuitive expertise is ubiquitous throughout all specialties and comes with experience. The ER doc that walks into a patient room and immediately diagnoses congestive heart failure with only a glance is demonstrating intuitive expertise. Intuitive expertise can be confounding to medical students who need to look up everything online. Still, it is this intuitive expertise we all gain through training and experience that makes us “real” doctors.

A superficial spreading melanoma. Lentigo maligna melanoma. Nodular melanoma.

Lucky Meisenheimer, M.D. is a board-certified dermatologist specializing in Mohs Surgery. He is the director of the Meisenheimer Clinic – Dermatology and Mohs Surgery. John

Meisenheimer, VII is a medical student at USF. 

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