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THE MILK OF HUMAN KINDNESS AND THE DIAGNOSIS OF MELANOCYTIC LESIONS


Dr. Hafeez Diwan

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When I diagnose things a certain way, the likelihood increases that I will diagnose those things in a similar or same way in the future. We are shaped by our training and our actions. This is akin to Shakespeare’s Macbeth getting more comfortable with murder after he had committed the first one.

It is the first murder (or diagnosis) that is often the toughest one. Remember that Macbeth had to be pushed and bullied by Lady Macbeth before he committed his first murder. Lady Macbeth didn’t think Macbeth was evil enough to commit murder (“…I fear thy nature; it is too full o’ the milk of human kindness…). She went so far as wishing to commit the murder herself, asking the spirits to “fill me from the crown to the toe top-full of direst cruelty!” This, by the way, is how we may sometimes feel when we feel that somebody is being maddeningly reluctant to pull the trigger and call something, for example, a melanoma.

But see what is happening. We have been taught some things and see things in a certain way. To take the example of melanocytic lesions: Certain lesions appear to us to be nevi and others spook us and make us think of melanoma. Yet others make us sit on the fence. These three categories (nevus, melanoma, atypical/of undetermined malignant potential) are in a way programmed into us. We cannot help but diagnose in the way we diagnose. And as a result, we may feel that somebody is not “decisive” or “too decisive” – when the truth is that they as decisive as then can be, given their education and experience.

Our psychology, as always, plays into the equation of how we diagnose. Dr. McKee refers to hawks and doves, and he is absolutely right. We think we are being objective, but we are often simply being ourselves. In my opinion, being ourselves is what we sometimes call “being objective”.

This is related to what is referred to as the “illusion of control” by psychologists. In the diagnostic context, we think we are in control of how we diagnose, but that is, I think, an illusion, as I have argued above. Most humans (in which category I think most dermatopathologists belong) believe they are far more in control than they truly are. Sleep, hunger, a fight with one’s spouse, how recently we attended a dermatopathology meeting where “worst-case” scenarios were presented (resulting in lawsuits) – all of these, in addition to the compound of nurture and nature that we are, factor into our diagnoses.

Or, as a celebrity recently stated (ungrammatically, but correctly): “I is what I is.”
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You have aptly summed up the entire practice of dermatopathology in less than 500 words Dr. Diwan. :)
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