Disparate Opinions

I am always puzzled by assumptions of equivalence. Does success in one field attest to the quality of an opinion about another? I am usually suspicious of the value of, say, a celebrity commenting on the significance of a particular product. It may be interesting, but does that actually certify its worth?

I realize that when it comes to health topics outside my specialty, I am sometimes rather late to the post. But occasionally topics are forced on me by my more curious patients who want to know what I think about them. Moles, for example.

Now, of course gynaecologists are called upon to comment on some dermatological issues –but often by default, and even then, mostly about areas that many dermatologists are reluctant to examine. Fair enough, I suppose –somebody has to be in charge. And yet even here, diagnoses are difficult without a biopsy. Especially here, in fact. It would be nice if there were some reliable rule-of-thumb that would sometimes obviate the need for an often painful and certainly anxiogenic procedure like sampling the tissue in question. Something like: oh, if it’s smaller than a dime, or not blotchy, leave it alone. But, alas, there are no such rules that work for us in the nether parts.

But the arm? Well, that seems to be a different matter: http://www.bbc.com/news/health-34551467

I have to admit, that until a rather starchy patient told me, I had never heard about it. I understand that it was all the rage when it was first reported, though: simply count the number of moles on your right arm and if there are more than 11 of them… well then you have a higher than average risk of getting skin cancer. The obvious corollary to that being that if you don’t, then you don’t… have an increased risk, that is. She liked the simplicity of the approach, and the proof that her being forced to learn the basics of arithmetic in school so many years ago was finally paying off.

But why, she demanded, and not too kindly, had we not found a similar rule applicable to the ‘private parts’ as she termed them in a barely audible whisper that I had to lean across the desk to hear?

“They’re made of skin as well, doctor,” she added in a more normal voice.

“Well…” I stalled, trying to think of a good answer to a rather naïve question -something that wouldn’t embarrass her. I hadn’t read the article she’d been describing and so I had to come up with something general. “Moles are just collections of pigment cells –‘melanocytes’,” I added to lend a little more credibility to my response. “They are a way the skin can protect itself against UV damage from the sun. The arm is exposed to the sun a lot…” I decided to leave it to her to decide why the arm might be different from that other area that seemed to be concerning her.

But she continued to stare at me as if I had only begun to answer her question. “And…?”

“Well, the more moles on the arm, the more it has likely been exposed to damaging UV light…” It seemed obvious to me. And yet her eyes never left my face and in the absence of any sign of understanding on her part, they were beginning to hurt. “The idea, I suspect, is that the more moles there are, the more that arm –or maybe the whole body- has needed to protect itself against the sun.” She blinked. “And so maybe that means it wasn’t able to protect against some of the damage…”

She rolled her eyes impatiently. “I understand that, doctor!” she said with a stern look on her face. “I’m not stupid, you know,” she added helpfully.

I smiled to disarm her, but I think she took the change of expression on my face as an attempt at refutation and a storm gathered in her eyes.

“Look. Moles are a protection mechanism against the sun, right?” she said testily. I nodded, glad of the chance to show I agreed with her. “So if you have moles somewhere, that means they’re there to help. Correct?”

I wasn’t completely sure if that followed –moles are just collections of melanocytes in the skin. They’re not necessarily related to sun exposure, either. Maybe some just appeared in an area by chance. It was an increasing number that suggested they were there for a particular reason. Counting them merely acknowledged that there was some sort of increased risk that demanded their presence. It was a crude, but easy way of quantifying that risk. But I smiled to show she was on the right track. “Yes, but especially if there are a lot of them –more than usual, I mean.”

“So there are usually less than 11 on the right arm…?”

“A little out of my area of expertise, but yes, I suppose so…”

It was her turn to smile –she was finally getting me to understand her point. “And how many down there” –and with that she pointed to where she was sitting- “How many down there,” she repeated to make sure I was still following her, “would you say was ‘usual’?”

“On the labia?” It was time to call a spade a spade.

She immediately blushed and unleashed her eyes once again to punish me. “We were doing quite well without using that disgusting word, doctor!” Then, realizing how silly that sounded, she softened her face and called off her eyes. “On the…” she forced herself to whisper the offensive word. “labia, yes. How many?”

I’d never really thought about a number before. “Well, it’s an unusual area to find a mole -it usually doesn’t get much sun…” I had a quick peek at her face and caught another blush in the making. “So I’d have to say even one would raise my suspicions.”

She looked uncomfortable when I said that. “So… three would be even worse…?”

I nodded –but slowly. Carefully. Now I understood why she had brought the subject up in the first place. Why that article had made her aware of the function of moles. “Have you noticed some on yourself… down there?” I said more respectfully this time, finally realizing how difficult it had been for her to introduce her concerns to me, a stranger -and a man.

She nodded bravely, but I could see tears gathering in those previously formidable eyes.

I smiled reassuringly and reached across the desk to touch her hand. “Would you like me to check, Esther?”

The relief was noticeable and a smile –a real smile this time- surfaced on her lips. “Please,” she said and actually squeezed my hand. “But I want you to come up with a three-or-less rule, okay?”

That sounded reasonable to me; maybe I could even get it published in the BBC News as well…

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