Dr Tim Cutler: The importance of lateral thinking in dermatology

I'm trying to get people to learn how to interpret what they see on the skin. It's not always easy but I live by a statement that common things occur commonly and certainly for nursing practitioners I'm trying to encourage them to think a little bit more deeply than just being flummoxed by seeing a difficult rash. So I like them to step back and I like them to look at the patient as a whole and talk to them and get a history, as one would for any other organ in the body, and get a good story as to what's going on. And then, once they've stood back and got a little picture of the patient as a whole, they can start to narrow down on the skin problem that's in hand. And I try and encourage people to think deeper than what they see on the surface. I try to get them to think, what's going on and where is it going on? Is it a superficial problem? Is it a bit deeper? Is it a bit deeper than that? What are the tissues involved? And once they've thought about that I get them to try and think about mechanisms. Why is this happening? What's doing it? What's the distribution? What does it look like? Is something very asymmetrical? Does it look odd? what sort of process might be causing this patient's problem. So I like a logical approach to it and once you adapt that you can sort of think along logical lines and that happens in my, when I'm seeing a patient it happens fairly quickly that process because I've been doing it a long time but that's the sort of process I go through semi-automatically when I'm confronted with a with a skin problem. Diagnosis is fundamental at whatever level you're practicing medicine. You've got to have some sort of concept of what you're trying to treat and how you're trying to treat it. And I've always taught that the phrase a leg ulcer is not a diagnosis. It's a problem. It's a symptom. It's a physical sign. It isn't a diagnosis. It's something that's telling you to look beyond what you're seeing and find out the cause and treat it appropriately. Too much inappropriate treatment happens because people are responding too quickly and they're not putting their thinking cap on. Infections in the skin are an ever-increasing problem. More and more patients are on chronic drug therapy, they're immunosuppressed, we've had a very successful organ grafting program in this country for decades. There's an awful lot of people out there on immunosuppressive treatment and some skin departments run special dedicated clinics for surveillance of this immunosuppressed group of patients. They get infections more commonly, they get skin cancers more commonly and they're almost an accident waiting to happen. But by regular surveillance. You can pick these things up often at a stage before they're causing much problem. But infections are, serious infections are becoming more common and of course we have the problem with decreased function of antibiotics and resistance. So the problem is beginning to compound and it's becoming more and more important to investigate and treat appropriately as far as infections are concerned rather than just reaching for the prescription and writing for a broad spectrum antibiotic prescription because it may be doing more harm than good in the long term. So I think we've got to get much more precise about treatment of infections, much more targeted and we've got to be using the right antibiotic for the right length of time and for the right reasons. So we've got to be a lot more selective.