Dermatology or Art?

Reading pathology is one of my favorite parts of dermatology. Often we take skin biopsies (small samples of skin) to help support our suspected diagnoses. The skin biopsies are processed in a laboratory for dermatopathologists and dermatologists to view under the microscope. And this is what such a specimen would look like. Isn’t it a beauty? The colors, the patterns, the subtleties. If framed, I think this holds its own in any fancy art gallery.

The truth is that medicine, especially dermatology, is much like art, and interpretation depends on the viewer. Two dermatologists walk in a room and see two different diseases. This is ever so apparent every Wednesday morning during weekly Management Conference at University of Miami’s Department of Dermatology. During this conference, rare or challenging dermatologic cases are presented in front of faculty, residents, students, and researchers. Residents and faculty are asked to describe what they see and give a differential diagnosis. It is interesting (and entertaining) to watch the highly esteemed faculty stand in different camps in support of various diagnoses for the same patient.

After the patient viewing or clinical photos, the pathology (what we see under the microscope) is presented, and this adds another level of complexity to the case. How does the pathology play into nailing the diagnosis? The pathology does NOT tell you the diagnosis. It SUPPORTS your clinical diagnosis. And it is not necessary to get pathology to make a diagnosis.

Things can get even more complex when the pathology stands in opposition to the clinical impression…. What is the next step in this scenario? This is when the knowledge and experience of a dermatologist as well as artistry come into play. There is no algorithm for what to do next.

At the end of the day, our goal is to make patients better. So whether or not a diagnosis is agreed upon, we need to map out therapeutic options. Again, there is no algorithm. Every patient is unique and every situation is unique. Dermatologists draws upon their unique clinical impression, available pathology, prior experiences and treatment success stories to craft a therapeutic plan that accommodates patients’ preferences and limitations. This is truly art.