“A Doctor Who Treats Himself Has a Fool for a Patient”
William Osler (1848-1919)

About four months ago, while showering, I felt a small, soft, movable, dome-shaped lesion on my lower abdomen. After drying off I tried looking at it and even used a magnifying glass. The angle of view wasn’t ideal but I decided to leave it alone and observe it (the “watch and wait” strategy). I briefly considered a few of the skin lesions that occur but didn’t think about it until the next shower, and then the next, and then the next, etc. Still, it did not worry me. I could not detect any change in size or firmness and remained (mostly) unconcerned.

In the last five or six weeks. I’ve lost a few pounds without trying. I have been on a diet since I was born at the hefty weight of 9 pounds 3 ounces. At that time, 82 years ago, a baby that size often meant the mother had diabetes mellitus, commonly referred to simply as diabetes (another, unrelated condition, usually due to a pituitary disorder, is called diabetes insipidus) but my mother wasn’t diabetic then or ever. As best I can determine she simply gained a lot of weight (approximately 50 pounds) during the pregnancy. I ruefully admit, with or without diabetes, there was a tendency for eating too much on that side of the family. My mother’s older brother was overweight but never diabetic. My grandmother was also mildly obese and did become diabetic in her fifties. William Osler, one of the greatest physicians in the history of medicine, quoted above, and a founder of the Johns Hopkins School of Medicine, also once said, “If you know all about diabetes, you know half of medicine.” As with so many things he was mostly correct. When I was a child, detailed studies of diabetes were not available but my guess is my grandmother’s diabetes was diet, rather than genetically, determined and, had she lost weight or had some of medications currently available, she could have lived longer than she did. Diabetes is a fascinating disorder and too complicated to summarize in this posting, but is generally well known.

In any event, I was always at least chubby. In the mid-1970s, when I was about 35 years old, I stopped getting on the scale when it hit 225 (I’m not tall). I went on a diet a medical student recommended that had been successful for him: liquid collagen in a glass of Tab (a precursor to Diet Coke) three times a day. That kind of diet soon makes you ketotic (the state diabetics obtain when uncontrolled) and, importantly, definitely depresses your appetite. The only other thing I took was a potassium tablet each day to make sure my heart didn’t stop. After three months, and weighing 60 pounds less, I resumed eating one day a week, when I would have broiled fish and vegetables. Kate, my wife, heroically kept up with this craziness. At the end, when I finally discontinued the vile-tasting liquid collagen, I weighed less than 160 pounds and desperately needed new clothes. Over the next 20 years I gained about twenty pounds and then seemed to find my ideal weight about 50 pounds less than my maximum.

Since I stopped working full-time 9 years ago, and with our living in New York half-year and travelling more than previously (at least before COVID), I added another ten which distressed me. Two years ago, we subscribed to one of those prepared food, weight-loss programs and I lost the ten but, after Thanksgiving of that year, it crept back. I have been trying to cut back on eating but not with great commitment. In the last three weeks, slowly but surely, and without any change in diet (I still have chocolate and ice cream more often than I should) I have lost five pounds.

Which brings us back to the skin lesion.

What could it be? Mostly gray with dark black on two opposite edges, it brought a couple of things to mind.. Skin bumps are very common as you get older and I have my share. Some of the ones that I can easily see are clearly keratoses (proliferation of the top layers of the skin to form benign lesions) and unequivocally benign. They are usually round or oval, only a few millimeters in greatest dimension, tan or brown and often have a granular surface. They can also be black when melanin pigment accumulates (“pigmented seborrheic keratosis” is not uncommon). That was my first and, for a while, dominant diagnosis.

We must interrupt this narrative again to point out that pathologists often think of the worst possible diagnosis when considering disorders in themselves or in their loved ones. I have been down that scary path several times in the past, always keeping my horrible presumed-diagnosis to myself, to avoid frightening family members. So, with that occupationally acquired disorder in mind I also thought of the often aggressive and metastasizing melanoma. However, with a deftly conceived combination of denial and procrastination, I managed to tell myself it was definitely a pigmented keratosis.

After losing another half-pound and then another half-pound (only people who have been overweight their whole life think in terms of half-pounds) in a relatively short period of time I looked a little more carefully at the lesion. I asked myself, why the weight loss? My bump is mostly gray but, as I well know, melanomas can lose their ability to make black melanin pigment (“amelanotic melanoma”). As I recall, amelanotic melanomas can be particularly aggressive. A few visions of my own liver full with metastatic melanoma, reminiscent of cases I’ve seen too often in my career, danced through my head.

Wait. I’m losing weight but I have a terrific appetite. I feel hungry all the time.

At this point the Osler admonition about foolish doctors came to mind and I decided to email a picture of the lesion to an outstanding, highly experienced dermatologist-friend as I found myself increasingly anxious. In my note to him I asked: “Is it pigmented seborrheic keratosis?” “Is it amelanotic melanoma?” “Should I have it excised?”

And I kept this all to myself, as you might guess, not wanting to alarm those I love, while thinking about all the plans that would have to be cancelled if …

My sleep that night was restless.

The next day, he responded and I groaned to myself because the problem wasn’t going to be solved. He needed a better quality photograph. Take a new picture, he advised, holding the camera six inches away and turn on the flash. A new photo? Why wasn’t that one good enough? 

Do I need a real camera for this, instead of my iPhone? (I know the iPhone camera is quite good with excellent resolution but, at this stage, I wasn’t thinking as logically as usual). I haven’t used my two SLR cameras in many months and, of course, the batteries need recharging.

The iPhone would have to do.

Now I looked even more closely at the new image before I sent it off. It appeared even scarier than before. Are the edges of the lesion a little fuzzy (a bad sign) or at least fuzzier than before? Is it a little larger than it was? Why did I wait all this time? Upon closer examination, I convinced myself it did not look quite as ominous as it did previously. I told myself, it doesn’t look exactly like a seborrheic keratosis and it doesn’t look exactly like melanoma. I’ve seen many examples of both processes in my career. I wished I had a microscopic slide of that lesion to look at it myself. That afternoon I sent off the new picture.

And those bad thoughts kept coming back. Should I call my good friend at Memorial Sloan-Kettering and ask him to set me up with a pigmented lesion expert? Should I have my care here in New York or back in Los Angeles? Thoughts of my medical school roommate came to mind. He had a melanoma in his second year and, within a decade, had widespread recurrence and died at Memorial. I thought of President Jimmy Carter and the highly successful treatment of his melanoma with new immunotherapy. Do I have to remind the surgeon resecting my lesion to be sure to save some tissue to prepare therapy specific for my tumor?

What about all the things I need to do? The line from “Yesterdays” by Charles Aznavour came to mind: There are so many songs in me that won’t be sung. I have two finished novels that need to be published. I have three other novels that need to be finished. I have a score or more of short stories in various stages of gestation. I have this blogpage that needs to be periodically fed.

Good grief.

My dermatologist is in Los Angeles. I am in New York. He is almost my age and isn’t always in the office all day, every day.

No response from him at 10 AM. Or 11 AM. Or 12 Noon. I reminded myself of the three-hour time difference.

At 1 PM, when I check my email, his response is there. My bump is just that: a bump. It is a larger-than-usual comedone (the fancy name for a blackhead). Blackheads are composed of dried sebum (oil) and dead skin cells. They usually form at the base of a hair and are the prime component of teenage acne. Comedones almost never get sent to a pathologist for diagnosis and, over many years, I’ve seen only one or two. My dermatologist advised me to squeeze it with an alcohol wipe and extrude the material.

One of my medical school teachers, the renowned surgeon LaSalle Lefall, often said that the only diagnoses you don’t make are the ones you don’t know and the ones you don’t think of. He admonished us to learn as much as possible to minimize the likelihood of not knowing. I failed to think of the diagnosis and called myself “dumb,” thinking of the reasons I didn’t make the right diagnosis. It looked like a tumor. I couldn’t visualize it well enough. I’m not a dermatologist. I’m not even close to being a teenager. Then, after squeezing it, I told myself the only important thing: My bump is gone.

Am I still the type of foolish doctor Osler spoke about? We’ll see the next time, but I would bet on it!