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A Day in the Life

Stephen Steiner, PA-C

Stephen Steiner practices dermatology at Gwinnett Dermatology in Snellville, Georgia. He has indicated no relationships to disclose relating to the content of this article.

I take care of skin for a living. Working in a dermatology practice for the past 7 years, I’ve grown to appreciate the prevalence of skin cancer, the intractability of an itch that can’t be scratched enough, and the heartbreak of an acne flare just before a prom. On any given day, I can see a range of patients, from a child as young as a few days old to a frail, elderly woman older than 90 years. Skin is something we all have in common, and unlike many medical issues that are internal, skin is on display for all to see and comment on. While the bulk of my practice involves the medical and surgical management of skin issues, I strive to treat the patient as a whole—mind, body, and spirit.

8:10 AM

The morning starts off with a bang. My first patient is an 89-year-old nursing home resident who has been itching for the past 6 weeks. Her son and primary caregiver relate that she has been itching since she started wearing her roommate’s clothing. When I ask about the roommate, they remark, “Now that you mention it, she’s been itching as well.” The skin scraping confirms my suspicion of scabies, and I know that I’m going to be itchy for the rest of the day.

9:30 AM

After a few mundane cases, I now see a patient who has been dealing with psoriasis for the past decade. He is absolutely ecstatic today. About a month ago, my supervising physician started him on a new biologic therapy. What numerous creams and pills could not accomplish in years, this new medicine has accomplished in just 4 weeks. His body is nearly free of psoriasis, and he is wearing clothing that he would never have considered before because of the embarrassment he felt over his skin condition. Within the dermatology world, the treatment of psoriasis has undergone a revolution within the past few years. It’s an exciting time to be a provider.

9:50 AM

One of the nurses knocks on the door and asks me to take a call. She knows that I hate to be interrupted when I’m with a patient, so I know this call is important. She hands me a chart and tells me the dermatopathologist is on line 7. When I submit a biopsy for review, I send along a brief differential diagnosis to assist the pathologist. Every once in a while, the dermatopathologist requires a complete clinical scenario to ferret out the diagnosis.

I pick up the phone, and after talking about our golf game briefly, he asks for the background on a patient. I explain that this lady has had a nodular eruption on her shins and a yellowish papule on her forehead. After discussion, we decide her picture best fits sarcoid. I’ll need to call her this afternoon to set up a chest x-ray and labs.

10:30 AM

My next encounter is with an 18-year-old whom I’ve followed for acne for the past 5 years. She has run the spectrum of acne treatment, from topicals to oral antibiotics. She is finally well controlled on birth control pills; they are relatively benign, from my point of view, and she has had no untoward side effects. Her need for me is coming to a close. Instead of focusing on acne during this visit, we talk about her future plans after high school. She is going to college, and I do my best to steer her in the direction of my alma mater. I leave the room with a smile. My role as a friend and mentor has superseded my job as a skincare provider today. In the grand scheme of things, the conversation we just had far outweighs my boring lecture on the pathogenesis of acne.

11:20 AM

I’m about to see my last patient before lunch. I look at the chart before entering the room, and my enthusiasm immediately drops. This is a 4-year-old boy with warts. I try to smile as I walk in and greet the mother and son. I am met with an immediate outburst of tears and wailing. My worst fears are now realized—and I am about to cry myself. After much cajoling and frustration, I’m finally able to examine the boy closely enough to see that he has six periungual warts. I explain to mom that warts are viral in origin and have a variable response to treatment. The mother nods understandingly and then states, “Just make sure that they’re gone after one treatment. I have a $30 copay, and I don’t want to come back just to pay you more money.” With these words, an already tough situation gets a bit more difficult. I explain to mom again that warts have a variable response to treatment, and I simply can’t guarantee that the warts will be gone after one treatment. I try to reassure her that I’m not here for profit, and I redirect my attention to the warts at hand.

My preferred treatment for warts is liquid nitrogen. Unfortunately, it’s exquisitely painful on the nail folds, and there’s a snowball’s chance of this patient holding still long enough for me to get an adequate destruction. Not only will I hurt this little boy, his warts won’t go away, and the mother’s suspicion of my motives will be confirmed—at least in her eyes. My recommendation is to use a topical keratolytic to irritate and debulk the warts, along with a healthy dose of tincture of time. Surprisingly, mom is amenable to this plan, and we agree that I will see her son back in 3 months. Hopefully, I can outlast these warts.

12:00 NOON

I have an hour to enjoy my peanut butter and jelly sandwich. I go over the labs and phone calls while I chew. I try to return all patient calls personally; however, I simply can’t handle the voluminous number of automatically generated refill requests that are faxed from the local pharmacies. I usually leave it up to the nurses to parse out the needed refills from the superfluous.

After all the patient care issues are taken care of, I stop by the office of one of my supervising physicians. He’s just gotten back from a CME meeting, and I always like to hear about the highlights of the meeting. He does a good job of culling out the critical elements for me; I like to think that I do the same for him.

1:30 PM

I enter the exam room to find a girl about 12 years old and her well-accoutered mother. Her mother greets me and says that her daughter is here to have a mole on her face removed. I look at the patient and see she has a 3-mm tan-brown papule on the right malar cheek; there is no evidence of abnormality. There is no medical necessity for this procedure, and as I begin to explain the ABCs of moles, the mother states how much her daughter is mentally traumatized by the presence of this mole on her face. Even the best plastic surgeon would leave a scar that would be noticeable on this cosmetically sensitive area. The daughter has been quiet throughout this whole visit, so I direct my questions specifically to her. The response couldn’t be more surprising. She tells me that the lesion doesn’t bother her at all, and it’s her mother who wants it removed.

Now, I don’t have a clue as to whom to believe. Maybe the mom is insisting on this to make her already pretty daughter more beautiful, at least in the mom’s eyes; maybe the daughter is deflecting attention and really wants it removed. I suggest that they talk at home about what they really want and what is best for the daughter over the long run. I give them the names of local plastic surgeons and leave the room thinking of Cindy Crawford.

3:30 PM

From about this time until the end of the day, my schedule mostly consists of adolescents with acne. I always try to gauge a patient before starting any therapy—I want to increase my chances of success with compliance. I have no doubt that the teenage princess with one small comedone will follow my regimen unfailingly. It’s the sullen, sulking teen with a combination of papules, pustules, and nodules that I worry about.

I have a love/hate relationship with my teenage patients. Acne is not something that clears quickly, and teens are notorious for demanding immediate results and not following directions (just like adults, now that I think about it). I try to convince them that a clear complexion is the pot of gold that they will be rewarded with in time. It’s an amazing thing to see that sulking teen who wouldn’t make eye contact with me 6 weeks ago turn into an outgoing person with clear skin. Those who blow off zits as a cosmetic condition have no idea about the impact acne can really have on a teenager’s self-esteem and social life.

4:30 PM

The day is coming to a close. I finish up my dictation and return a few patient phone calls. It has been a good day so far. I worked hard, saw patients with a variety of skin problems, and made a positive impact in their lives. I race out the door and soon find myself at home, where I can devote the rest of my day to the true purpose and joy of my life—being with my family. JAAPA