When the past becomes present : JAAPA

Secondary Logo

Journal Logo

AAPA Members can view Full text articles for FREE. Not a Member? Join today!
The Art of Medicine

When the past becomes present

Maurer, Brian T. PA-C

Author Information
JAAPA 36(6):p 50, June 2023. | DOI: 10.1097/01.JAA.0000931460.42568.85
  • Free

“I've sent a number of patients to you over the years,” I say. “Nearly all of them—actually, I would say all of them—most likely came to you indirectly by way of the only pediatric dermatologist who was practicing in the region back then.” I drop the mutual colleague's name, and the surgeon nods his head.

I close my eyes against the intense brightness of the overhead light and bring to mind the round face of an olive-skinned dark-eyed toddler. Silently, I sift through the memory banks of my mind, searching for her name. I can't recall the year, but it must have been more than a decade ago—yes, at least that long.

“I remember one patient in particular,” I say, “a little girl, just a toddler, who presented with a lesion on the calf of one leg. There was no significant family history, but just the same, I was concerned. I suggested a consult with the pediatric dermatologist, but the mother pushed back. In the end she elected watchful waiting; I agreed to see the child back in a couple of months.

“I really didn't like the look of it at the follow-up visit,” I ramble on. “I finally convinced the mother to take the girl for the consultation. That's when the dermatologist referred the child to you for an excisional biopsy. As I recall, the pathology report showed melanotic spindle cells, and—”

“Wait, I remember this kid,” the surgeon says. “Yes, I remember. She had an older brother as well, right? This was such a difficult family to work with. Initially, the mother didn't want to have the biopsy done; then, she fought the wide excisional follow-up surgery. That's when I found out the backstory. It was the father. He was a big, imposing man; very abrupt, very curt. I remember how uncomfortable I was meeting him. He challenged everything I said. In the end I sent the biopsy specimen to an outside dermatopathology lab in New York for a confirmatory diagnosis. I even wrote letters—to the family, to the insurance company, to everybody involved.” He pulls back and straightens up a bit. “Now that I think of it, you and I must have talked over the phone at some point about this kid.”

“I'm sure we did. While you were working on things from your end, I was doing my best to educate the parents on my end. I do remember meeting the father—very imposing, as you said. Finally, after a lengthy discussion, I told the mother that the little girl's chances were guarded if she didn't follow through with the surgery.”

The surgeon leans back on his stool. “Did you know that we had to make arrangements for the mother to bring the child in secretly for the final procedure? The father didn't find out until after the fact. I was actually worried for the mother's safety. Thankfully, the wound margins were clear. I guess it all must've worked out, because I never saw them again.”

“Well, I did. The mother brought the girl back to our office for her 2-year well-child check. The wound was well healed by then. There was the scar, of course; but that couldn't be helped. At least the cancer was removed before it had a chance to metastasize.”

“And she went on to do well?” the surgeon asks.

“Yes. The mother brought her back for regular checkups and sick visits. Eventually, the family moved away. I believe that they may have returned to their country of origin; I'm not sure.”

“Turn your head a bit more to the left,” the surgeon says. “Good. Now, stay still as a statue.” He leans in, and I hear the repetitive metallic click of the needle holders. Shortly, he's finished: the skin graft is done.

“My assistant will go over wound care for the donor and the graft sites with you. I'll see you back in 2 weeks to check them. They should be fully healed by then.”

The assistant pulls the surgical drape from my eyes. I blink in the light, then focus on the surgeon's face. “Thank you for your attentive care—and for your kindness,” I say.

The outer edges of his eyes crinkle above his surgical mask. “Oh, you're very welcome,” he says. Then, with a hand on the door of the surgical suite, he turns momentarily, and our eyes meet.

“I really admire you guys who work in pediatrics,” he says. “You've got to have the skill set to treat the family as well as the child. Not everybody does. And,” he adds, “you've also got to have the patience of Job.”

As I look back on my four decades of clinical pediatric practice, his words feel like a small benediction.

Copyright © 2023 American Academy of Physician Associates