Trading places

In a transition like no other, Sonia Wolf describes her experiences of being a medical student, then a patient, and back again

We had just moved into a new house: lovely area, great flatmates, close to college and the pub, but with a terrible shower. One night, using a vaguely remembered principle from elementary physics, I crouched down in the shower in a futile attempt to increase the water pressure. I noticed a small black mole on my inner thigh that had not been there before.

And so my story begins. Innocent enough, a chance discovery that has altered my life and the way I practise medicine. I went from medical student to patient and have come back again. I am sure that every medical student has experiences as a patient, but a serious illness made me both question and appreciate our roles as doctors and has shone a new light on my life, personal and professional.

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I showed the mole to my medic flatmates, my friends, and my family. They all thought I was that classic case-the medical student hypochondriac. The one who thinks that the palpitations they get after exercise are more than just a sign of chronic unfitness. The one who thinks that their tiredness is a complex endocrine disorder, not just the result of too many nights out. Unconvinced, I went to see my general practitioner, who reassured me it was probably nothing serious, as it was flat and regular in shape, although she excised it to be on the safe side. I forgot all about it and continued my third year placements.

Melanoma in situ

About a month later I was enjoying a lie-in on a Saturday morning, when my flat mate brought me a letter. It said that the excised mole had had some abnormal cells and that I should contact the surgery immediately. It was at this point that I started to seriously worry. Until then I too had thought I was just another overanxious medic. Because it was the weekend, the surgery was closed, and I had to wait until Monday. I cannot remember how I passed that weekend.

On Monday I rang the surgery who told me to ring back at 11 30, when I could speak to the general practitioner. At the time, I was on a surgical firm, spending a lot of time in theatre. At 11 25, I slipped out of theatre, still in my scrubs and mask, into the hospital corridor. I spoke to the general practitioner, who said that ordinarily she would not discuss this sort of thing on the phone, but as I had rung especially she would make an exception. She told me that the pathologist's report confirmed "melanoma in situ." I walked back to the changing rooms and broke down among the neat piles of freshly washed scrubs and rows of soap dispensers.

Afterwards, everything happened very quickly. I saw a dermatologist the next day, who organised a wider excision to make sure the melanoma had not spread. In the immediate aftermath, one question I was often asked, both by doctors and well meaning friends, was "Do you sunbathe a lot? Have you ever been sun burnt?" Although I understand the reasons behind these questions, I found it quite upsetting at the time, as if I was being blamed for the abnormal proliferation of my cells, as if it was my fault. I had sometimes sunbathed but no more than most people.

Like, I suspect, most young people, I did not imagine that cancer could happen to me at my age. In addition, my Mediterranean ancestry meant I rarely burnt, and I was far removed from the classical pale and freckly northern European you typically associate with skin cancer. Something I have certainly taken from this is that an atypical patient is not an invincible one-low risk does not equal absence of risk.

Can you spot the melanomatous cells?

An experience for betterment

The wider excision fortunately showed no spread and was a fairly minor procedure, leaving only a small scar. I had regular check-ups for a year, and can still get a two week referral to a dermatologist if I present to my general practitioner with a new or altered mole. The larger scar was an emotional one, one that has still not quite healed, over a year later. The fear of dying in my 20s, however unlikely, has still not left me. In this aspect, being a medical student is not helpful. On being diagnosed with melanoma, words and phrases from lectures flooded back to me-"very aggressive," "poor survival rates," "the worst type of skin cancer," and so on. A little knowledge is a dangerous thing, especially in the hands of a third year medical student. I now tell myself that whatever problems I may have, be it with work, relationships or family, they can never be worse than the fear of dying that grips you like a fist and only ever relaxes but never quite lets go.

As a patient I learnt to perceive the actions of doctors differently to my perception of them as a medical student. At one appointment, a doctor had some students sitting in with her, students only a couple of years older than me-ironically, at the hospital where I had just completed a 10 week placement. While I was changing after being examined, I heard her ask them, quite audibly on the other side of the curtain "And what socioeconomic groups are more likely to get melanomas? Higher class or lower class?" Had I been the medical students, I would have probably just appreciated a chance to get some teaching; however, as a patient feeling frightened and vulnerable, hearing others discuss your socioeconomic group or your sun exposure is annoying at best, and hurtful at most. I know that, if I am ever in that position, I will discuss the patient's condition with my students when they have left the room.

I remembered a lecture I had had about the psychology of cancer, and how people who had positive attitudes had better survival rates than those who felt depressed by their diagnosis. I remember naively thinking at the time, as I'm sure many other students do: "If I had cancer, I would try to stay positive." In reality, this is hard to do and led to me feeling guilty that by feeling depressed, and at times hopeless, I could be worsening my outcome. When circumstances are beyond your control, your emotional response is also largely beyond control, and that is something not to worry too much about.

Although I no longer have regular follow-ups, I am aware of what happened to me and an ever increasing number of people. In 2002 alone, there were 6523 new cases of malignant melanoma diagnosed, and it was the second most common cancer in people aged 20-39, according to Cancer Research UK (http://info.cancerresearchuk.org:8000/cancerstats). I am now never without strong sunscreen at the first hint of sunlight, and I cover my legs and arms in a manner that would not be out of place in Saudi Arabia. It also means that I cannot enjoy beach holidays, barbecues, and picnics, even covered, without worrying about the risks. But I try to live my life as normally as possible. Although this is an experience that will stay with me for the rest of my life, I hope that I will be a better doctor because of it.

       

           

	LIFE Trading places        Sonia Wolf (January 2006)
	Pragna Rao (December 23rd, 2006)        Professor of Biochemistry, Kamineni Institute of Medical Sciences, Narketpally, AP, India mnaprag@hotmail.com
	Having recently undergone a serious surgery, and being a doctor, I can identify with Sonia Wolf's "Trading places". I gained a different sort of insight when as a patient, I lost the right to call my body my own. Strangers in the garb of nurses and technicians, turned me over efficiently, poked needles into me and carried out procedures on me mechanically, as if I were a mannequin in the clinical skills lab. All this was done kindly, courteously and gently. As a doctor, I appreciated their professionalism. But as a patient, being handled by so many people whom I barely knew made me feel vulnerable, afraid and embarrassed. The different perspective I gained as a patient now makes me more aware that my own patients are individuals like me with names, homes, hopes and fears.