(February, 1999)

GP Did More For Me Than Derm
from Mark M.

Hi Ed. I've just read the January mail and finally can't stay lurking away.

I'm 26, from Ireland and have had P for around 19-20 years. After years using the same mild steroid ointment I moved jobs early last year. This required a medical [exam], after which the doc suggested I call back if I get the job and he'd see if he could help [my P].

Now, while having tried various derms and returning to my original treatment many times over the years, I was skeptical about this family doc.

But what the hell? New town, new start. So, he duly prescribed Ditrocream of increasing strength. This has, I must say, brought a lot of relief. Although it now seems a constant watch to see where the next spot has appeared.

I'm presently trying Dermovate on my scalp, which has unfortunately gone galloping out of control.

Basically I guess the ordinary doc can sometimes be as much help as anyone, if he is in anyway interested in what he does.

Of course this time of year in Ireland has carried the usual consequences of being wet and wild. That's the weather by the way. The social aspect has also been hectic and that, consequently, leads to letting the P treatments slip. (Obvious in my case, not all Irish people...)

Well, thanks to yourself and everyone else who has their say [at FLAKE HQ] for all the laughs and news, Go raibh mile maith agaibh -Mark M..

*****

Ed's Response: Good to hear from you, Mark. You've touched on something that has had me scratching my head for several years. I ask myself, "Since so little is known about P, and the list of treatment regimens is manageably short, why do we need medical specialists to attend to us?"

There's been a perceptible evolution of medical practice protocol in the U.S. over the last few decades. (At least I've perceived it.) Not so long ago, one went to a specialist on occasion and then returned for routine treatment to one's general practitioner (also referred to as "family doctor" in the U.S.). There was a line of communication between specialist and family doctor. With the exception of major ailments (e.g., cancer) the specialist would see the referral, make a recommendation, pass that along to the GP, then the GP would oversee on-going out-patient administration. That's changed now. Now health care in the U.S., more and more, involves a "team." One doesn't go to a specialist on occasion anymore; one adds a specialist to his/her "healthcare team."

This might be an erroneous perception on my part. Perhaps as I grow old and fall to pieces I'm just graduating into more diverse and interesting layers of health care. But the P issue strengthens my perception. What does my derm do that a GP couldn't do? It's quite obvious that my P regimen is one of maintenance. I've abandoned the pursuit of blemish-less skin. I've accepted the fact that I'm a flaker. These days I strive toward minimums, not towards zero. I make my twice yearly trips to the derm merely so he can fulfill his obligation to "observe" me before continuing to refill my prescripts.

And this is just an observation. I happen to enjoy visiting my derm and find his practice a comfortable place to visit for a couple of hours a year. I probably would not shift my P care to my family doctor even if it was proposed, because my visits to the derm cost about US$50 while a visit to my family doctor is inevitably twice that or more.

Nonetheless, it still makes you wonder if team care is as efficient as it should be. Technology is going to change things, I think. Two stories: For some years I belonged to a GP Group that was very large and diverse within itself. It was not at all unusual for my Dr. to send me off to other doctors for particular tests and procedures. But then I would always return to my doctor. After these tests, I would often sit with my primary doctor while he picked up the phone, dialed an abbreviated number (to another internal extension), listened intently and took notes without saying a word. I asked and my GP explained: The various specialists who administered my tests dictated the results and their opinions and by calling the appropriate extension my GP listened to that dictation. I thought that was very efficient.

In the late seventies, I was working for NASA on an experimental satellite project. We were giving away free satellite time for "worthy" social experimentation. One project involved separating the gantry (the doughnut shaped device with a gurney in the middle) from the image processing computer of a CAT scanner (then called a CT Scanner) and connecting the two pieces over long distances via satellite. The objective of the experiment was to determine if smaller clinics in remote locations could make do with a gantry and not have a central processor and image generator—the hypothesis being that CT scans would be much more widely available if smaller rural healthcare facilities had only to purchase gantries and be linked via satellite to regional medical centers with the processors. The experiment worked fine, but the manufacturers of CT Scanners could not be convinced to sell their devices in pieces. Nor did the radiologists like the idea. There was fear of long-distance malpractice, some local physician bungling the job and trying to blame the distant radiologist who processed the imagery and rendered an opinion. In the end our good idea was perceived as everybody else's problem.

You hit on another observation of mine—but I'll be briefer about this one. For years you settled for a relatively low-potency treatment regimen and have only recently graduated up to stronger stuff. You have been generally pleased with the results. For years I tackled my P very aggressively; always wanting to try the next thing; never settling for status quo on lesion activity. It was a very manic depressive time. Something would work wonderfully—like intralesion steroid injections—but only for awhile. Every time my P flamed I would feel worse psychologically. I was like Sisyphus, pushing that boulder up the hill only to have it roll down again. These days I'm more inclined to wait. I engage in new regimens, try new drugs, with optimism, but fully aware that relief is probably temporary. These days I look at myself and ask, "Are you bad enough to go through all that again? Can't you live like this for a few more days (or weeks, or months)?" As example, at the end of last year my hand P really flamed. Yet it wasn't until January 4th that I decided to undertake the nightly occlusion regimen. Here it is, just January 8th, and my hands are much, much better. I am enjoying that fact. I probably won't occlude again until February, even though I'll probably start flaming again in a few days. But if I'm lucky, it will take me until February to forget how much I am enjoying my quiet hands right now. My cup, as they say, is half full—not half empty.

Stay in touch, Mark. -Ed

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