On the theme ‘A case I’ll never forget’, Dr Hastie Salih writes about a patient who decided to bypass the dermatology waiting list by removing his own skin lesion
The patient shuffled into the consultation room and sat down heavily on the chair next to my desk as my cup of tea overspilled.
‘Hello, doc.’ I was welcomed by a booming but somewhat gruff voice.
I smiled at him. He reminded me of someone – the red-tainted beard and moustache, thinning ginger hair and an angular face. A straw-hat concealed part of his face.
‘How can I help you today,’ I said, wondering why he was wearing a straw hat in winter.
He fixed me with an intense stare. Was it Ed Sheeran I was thinking of? Ed was smaller and younger, I decided.
‘I’ll have a cuppa with one sugar, please,’ he proclaimed, eying my cold tea.
How were we GPs told to relate to our patients? Well, Dr Carl Rogers, the founder of person-centred therapy, postulated ‘with unconditional positive regard’.
So, I grinned as he continued speaking.
‘Remember the skin lesion I showed you a few weeks ago?’
I looked at my notes on the computer. They stated: ‘One centimetre hyperkeratotic, light-brown lesion of the left upper earlobe, not growing in size, no signs of malignancy.’
‘Ah,’ I said, ‘I gave you an ointment and told you to come back after two weeks. That was two months ago.’
The patient raised his eyebrows and chortled.
I tried craning my neck to examine his left earlobe.
‘Let’s have a look to see if the lesion has improved,’ I said irritated by his nonchalance.
‘No need, doc,’ he replied.
I gave him a puzzled look.
‘I cut it off myself.’ He hesitated. ‘Together with part of my ear!’
I suppressed a gasp and felt like snatching his straw hat off him to peer at the scene of crime.
The patient promptly took his straw hat off and proudly presented his mutilated earlobe.
My heart sank as I watched him feel the remaining part of his maimed earlobe.
‘Nice and smooth now,’ he proclaimed.
What if the skin lesion was pre-cancerous actinic keratosis, I thought looking at my computerised records.
‘I did tell you to come back in two weeks,’ I remonstrated, trying to keep the GMC out of my mind.
The patient’s features softened.
‘Well, doc, you said the waiting times of the dermatology departments were very long.’
I frowned, wondering if my ‘unconditional positive regard’ was still justified.
‘So, I decided to help out by operating myself,’ the patient announced triumphantly.
I opened my mouth to protest, but the patient was oblivious to my terror.
Now, we will never know what the lesion was, I thought, feeling uneasy. I took a deep breath. I would put this patient narrative into my appraisal file. Reflective practice began with the oxymoron of ‘certain uncertainty’. I felt my neck muscles relax.
The patient stood up and patted me on the shoulder benevolently.
‘Don’t worry, doc. I know the pressure you GPs are under – one referral less!’
I shook my head while the patient turned to leave the room declaring, ‘Our NHS must be saved’.
As the patient turned the handle of my door, I remembered who he reminded me of and said inaudibly, ‘Thank you, Mr Van Gogh’.
Dr Hastie Salih is a GP in London
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Both a worrying and amusing story, prompting me to share something not dissimilar, which happened very recently. I had a very painful throbbing big toenail peri-ungual infection which had been brewing for several days. The skin around the toenail was hot and red with a visible focus of pointing pus. I knew antibiotics alone wouldn’t be sufficient and the pus needed draining, but felt it was too trivial to attend A&E for. I have incised such superficial foci of pus for patients myself in the surgery many times in the past. As such I considered doing it to myself at home, but mindful of GMC guidance about self-treatment I was a good patient and attended my GP who promptly advised me to attend A&E. I explained why I didn’t want to do this and said if he provided me with a dressing pack and a blade I would do it myself. After hesitation on his part, and insistence on mine, I was led to a treatment room and with the assistance of a slightly astonished practice nurse who assisted, I duly did just that. Immediate relief of pain, she helped me dress it, an A&E visited was averted, and it healed fully with no problem. .