If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.
They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.
Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.
What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.
Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.
I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.
We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.
"How’s your eczema been?" I asked.
"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."
Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.
Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.
I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.
Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "
I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.
"Went away," he said. "No problems anymore." I’d never have guessed.
What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.
So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.
There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.
Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.
Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.