Opinion
A PIECE OF MY MIND Peter A. Selwyn, MD, MPH Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
Corresponding Author: Peter A. Selwyn, MD, MPH (peter.selwyn @einstein.yu.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Skin Deep My mother asks me to apply the bacitracin to the small open sore on her back, at the site of a skin biopsy that has not healed properly. She lifts her shirt up from the waist so I can get a better look. On her lower back, I see a 2 × 2-cm red-bordered lesion, with some central necrosis and crusting, just below the beltline. I have noticed that lately she has demonstrated less modesty about enlisting my help or assessment involving different parts of her body—I am still not sure whether this reflects the disinhibition of starting to lose some of her cognitive edge, or maybe the surrender to practicality of a 92-year-old who realizes she can’t manage her daily life as independently as before. Either way, it makes me slightly uncomfortable; not for lack of familiarity with the landscape of the body, in my 30 years as a physician, but rather that my mother is leading me into a territory that I may not feel ready to explore with her. The lesion does not look infected and seems typical for a slowly healing biopsy site. I apply the antibiotic ointment and cover it with a Band-Aid. I notice that the surrounding skin looks surprisingly smooth and delicate; if I were to look at it in isolation, and didn’t know whose body it belonged to, I might even think it was from a young child. I remember being 6 or 7, coming home from the park after scraping my knee in the playground, and my mother ceremoniously applying bright orange Mercurochrome to the abrasion; it stung, but felt healing in her attentive hands. I reassure her that the biopsy site is healing well, that I don’t think she needs oral antibiotics, and that I will check it again when I see her in a few days. My mother continues to live alone, with a gradually increasing amount of home health aide hours to help with daily activities, lately increased even more after a rotator cuff injury compromised the use of her right arm. Her recent history has included a growing list of injuries related to falling at home: a broken pelvis five years ago; a broken hip and femur two years ago; and occasional bruises, abrasions, and one facial laceration requiring a late-night emergency department visit last year. Yet despite her overall, increasing frailty—she is 4′ 11″and shrinking—she has continued to be as active as she can, fearlessly rolling her walker down Manhattan’s busy sidewalks like a diminutive chariot driver. Abruptly widowed twice in her life—first in her 30s following my father’s suicide when I was an infant, then again in her 80s when her second husband died of a sudden arrhythmia—she has a unique determination and hardiness that are remarkable, an enduring will to just keep going. Her constitution has always seemed to be based on doing what she needs to do, no matter what, but it seems lately like the threads may be getting a little frayed, the vulnerability a little more evident, as if her protective layers are slowly peel-
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ing away. Nurses talk a lot about “skin integrity,” and I am realizing that this is true on a social as well as a cellular level. A little more than five years ago, before she broke her pelvis, she was living completely independently, driving from Manhattan to eastern Long Island every weekend to the summer house she had presciently built in the early 1970s (against the advice of my grandfather, who didn’t think single women should be buying real estate). Then, starting in her late 80s, she had two minor car crashes, and we struggled lightly with each other for more than a year about whether it was still safe for her to drive, until finally, after the third accident—which she still insists was an early case of unintended acceleration in Toyotas—she reluctantly gave up the keys. The last year or two have seen an increasing pace of giving up things. After giving up driving, it soon became clear that she was having trouble balancing her checkbook and managing her banking and retirement accounts, which I now oversee. Over the past year she has gradually stopped cooking for herself, and I’ve started to worry about her using the stove at all, especially in the evenings, insisting that she never leave the kitchen when the stove is on, so that she doesn’t forget to turn it off. More recently, it has become clear that she is no longer able to manage her regular medications or medical appointments, and I have been helping her with these tasks as well. I have started to add adult diapers to the list of items she asks me to pick up for her when I visit, along with the orange juice, Ensure, and lox from the local deli. There is a matter-of-factness to all this; sometimes she seems perplexed or indignant over these small but growing losses, but mostly they seem to come without judgment; we focus on how to meet her changing practical needs, without dwelling too much on the implications. First reluctant to accept the home health aide, she is now accepting and even relieved as we have gradually increased the hours over time. It is in this trajectory of giving up things, losing certain higher executive functions, that her skin has seemed to be the last frontier, now showing consistent signs of breaking down, or taking longer to heal after a minor injury. When I come to see her, in addition to episodes like tending the biopsy site on her back, she will often show me various areas on her skin that signal some signs of distress, seeming to appear more frequently now. I make a mental inventory of each of them at every visit, like the bruise on her shin where she has bumped into a low table, bright purple with surrounding red splotches, that is healing very slowly if at all, or the painful callus on one of her toes that at times makes it difficult to walk, lately showing some redness and scaling, suggesting a new fungal infection. The delicate, thinned-out skin on her lower legs swells at times if she has been on her feet, and JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/06/2015
33
Opinion A Piece of My Mind
occasionally leaks or breaks down slightly under the pressure of the accumulated fluid. In all of these areas, there is sometimes a musty and slightly acrid smell, redolent of decay. It is as if her core strength, perseverance, and spirit remain strong, but the vessel they are housed in has begun to show some weak spots on the surface. I find myself wishing we could do something to keep these defensive layers more durable. I remember my daughters, when they were young, having the most impossibly soft, resilient, and sweet-smelling skin, smooth and uncharted, vulnerable but strong. Now they are in their late 20s, still very youthful, but starting to have a few wrinkles around their eyes, foreheads, and hands. They have not yet had children of their own, but I can imagine how transformative a pregnancy would be for each of them, as the skin is challenged to keep up with and contain the miraculous changes going on inside, while the body generates and ultimately releases new life into the world. I recently sat at the kitchen table in that small house on Long Island that my mother built those many years ago. My mother was there that weekend, as were both girls, and my wife. As we all sat eating breakfast at the table, my eyes passed from my mother’s wrinkles and bruises to my daughters’ young adult faces, and I imagined them as mothers and then grandmothers in their own right, with the history of what I hope will be their long and happy lives written into the texture of their own skin. I notice the back of my own hands, tanned from this summer’s sun, freckled more than usual, but also more wrinkled than I would have thought when I was younger, and I also notice some larger brown lentigines (which somehow now seems less harsh a term than “age spots”) that I don’t remember seeing before this year. Since my mid-50s, I’ve seen that the skin on the distal parts of my lower legs and arms has gotten thinner and more finely wrinkled, and I wonder sometimes when it might start to show some of the same changes I have seen in my mother’s skin over these past few years. (In an ambivalent response that seems to fluctuate between self-care and vanity, I have started to use moisturizing creams on these thinning-out areas. In our local chain pharmacy, I feel like I have entered a brave new world: the skin moisturizer aisle was one of which I had been
blissfully unaware for years, and now as I look down the long rows of skin rejuvenators, wrinkle smoothers, and a dizzying array of “antiaging” products, I realize it is not an accident that the fear of death has spawned such a multibillion-dollar marketplace. Imagine such products in a society where age and the wisdom of the elders were valued, even venerated, not dismissed or marginalized.) I am reminded how frequently the body sheds its skin, constantly making new layers, so that even the skin that I am seeing in myself and others around me is a symbol of transition, of constant change. And yet within that unending transformation, each age is clearly defined and demarcated by its own, as it were, skin. My dermatologist has an etching in her office with the title “The Skin Doesn’t Lie,” and I suppose this is true. It also seems to carry a lot of weight: physical attraction, eroticism, repulsion, hatred, all can be translated into responses to other people’s skin, its texture, configuration, color, which seems to give the lie to the adage about beauty being only skin deep. Being thick-skinned, feeling comfortable in my own skin, making my skin crawl: all of these seem to invest much meaning in our surface covering, that we take for granted until it loses its integrity. I flash back to my postcollege experience, spending a year before medical school working as a nursing assistant in the operating rooms at Massachusetts General Hospital, where I would watch as the surgeons painstakingly sheared off healthy skin from the unaffected limbs of burn survivors, pulling the elastic ribbons of skin off the bleeding base from where they had just been cut, and applying them like wallpaper to the raw, open areas lying exposed from the burns. I recall thinking how violated these patients’ bodies seemed to be, how their skin could no longer contain and protect them, could not effectively maintain the separation of inside from outside. With all her frailty, accumulated injuries, losses, and indignities, my mother is still getting up every day, living in her skin, making breakfast, reading the paper, taking care of what she can. Looking at her bruises and sores, I feel both uncomfortable and admiring of how intact she is as she heads past 92 and beyond. I hope my own skin can hold me together for that long too.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
34
JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/06/2015
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A PIECE OF MY MIND Peter A. Selwyn, MD, MPH Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.
Corresponding Author: Peter A. Selwyn, MD, MPH (peter.selwyn @einstein.yu.edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Skin Deep My mother asks me to apply the bacitracin to the small open sore on her back, at the site of a skin biopsy that has not healed properly. She lifts her shirt up from the waist so I can get a better look. On her lower back, I see a 2 × 2-cm red-bordered lesion, with some central necrosis and crusting, just below the beltline. I have noticed that lately she has demonstrated less modesty about enlisting my help or assessment involving different parts of her body—I am still not sure whether this reflects the disinhibition of starting to lose some of her cognitive edge, or maybe the surrender to practicality of a 92-year-old who realizes she can’t manage her daily life as independently as before. Either way, it makes me slightly uncomfortable; not for lack of familiarity with the landscape of the body, in my 30 years as a physician, but rather that my mother is leading me into a territory that I may not feel ready to explore with her. The lesion does not look infected and seems typical for a slowly healing biopsy site. I apply the antibiotic ointment and cover it with a Band-Aid. I notice that the surrounding skin looks surprisingly smooth and delicate; if I were to look at it in isolation, and didn’t know whose body it belonged to, I might even think it was from a young child. I remember being 6 or 7, coming home from the park after scraping my knee in the playground, and my mother ceremoniously applying bright orange Mercurochrome to the abrasion; it stung, but felt healing in her attentive hands. I reassure her that the biopsy site is healing well, that I don’t think she needs oral antibiotics, and that I will check it again when I see her in a few days. My mother continues to live alone, with a gradually increasing amount of home health aide hours to help with daily activities, lately increased even more after a rotator cuff injury compromised the use of her right arm. Her recent history has included a growing list of injuries related to falling at home: a broken pelvis five years ago; a broken hip and femur two years ago; and occasional bruises, abrasions, and one facial laceration requiring a late-night emergency department visit last year. Yet despite her overall, increasing frailty—she is 4′ 11″and shrinking—she has continued to be as active as she can, fearlessly rolling her walker down Manhattan’s busy sidewalks like a diminutive chariot driver. Abruptly widowed twice in her life—first in her 30s following my father’s suicide when I was an infant, then again in her 80s when her second husband died of a sudden arrhythmia—she has a unique determination and hardiness that are remarkable, an enduring will to just keep going. Her constitution has always seemed to be based on doing what she needs to do, no matter what, but it seems lately like the threads may be getting a little frayed, the vulnerability a little more evident, as if her protective layers are slowly peel-
jama.com
ing away. Nurses talk a lot about “skin integrity,” and I am realizing that this is true on a social as well as a cellular level. A little more than five years ago, before she broke her pelvis, she was living completely independently, driving from Manhattan to eastern Long Island every weekend to the summer house she had presciently built in the early 1970s (against the advice of my grandfather, who didn’t think single women should be buying real estate). Then, starting in her late 80s, she had two minor car crashes, and we struggled lightly with each other for more than a year about whether it was still safe for her to drive, until finally, after the third accident—which she still insists was an early case of unintended acceleration in Toyotas—she reluctantly gave up the keys. The last year or two have seen an increasing pace of giving up things. After giving up driving, it soon became clear that she was having trouble balancing her checkbook and managing her banking and retirement accounts, which I now oversee. Over the past year she has gradually stopped cooking for herself, and I’ve started to worry about her using the stove at all, especially in the evenings, insisting that she never leave the kitchen when the stove is on, so that she doesn’t forget to turn it off. More recently, it has become clear that she is no longer able to manage her regular medications or medical appointments, and I have been helping her with these tasks as well. I have started to add adult diapers to the list of items she asks me to pick up for her when I visit, along with the orange juice, Ensure, and lox from the local deli. There is a matter-of-factness to all this; sometimes she seems perplexed or indignant over these small but growing losses, but mostly they seem to come without judgment; we focus on how to meet her changing practical needs, without dwelling too much on the implications. First reluctant to accept the home health aide, she is now accepting and even relieved as we have gradually increased the hours over time. It is in this trajectory of giving up things, losing certain higher executive functions, that her skin has seemed to be the last frontier, now showing consistent signs of breaking down, or taking longer to heal after a minor injury. When I come to see her, in addition to episodes like tending the biopsy site on her back, she will often show me various areas on her skin that signal some signs of distress, seeming to appear more frequently now. I make a mental inventory of each of them at every visit, like the bruise on her shin where she has bumped into a low table, bright purple with surrounding red splotches, that is healing very slowly if at all, or the painful callus on one of her toes that at times makes it difficult to walk, lately showing some redness and scaling, suggesting a new fungal infection. The delicate, thinned-out skin on her lower legs swells at times if she has been on her feet, and JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/06/2015
33
Opinion A Piece of My Mind
occasionally leaks or breaks down slightly under the pressure of the accumulated fluid. In all of these areas, there is sometimes a musty and slightly acrid smell, redolent of decay. It is as if her core strength, perseverance, and spirit remain strong, but the vessel they are housed in has begun to show some weak spots on the surface. I find myself wishing we could do something to keep these defensive layers more durable. I remember my daughters, when they were young, having the most impossibly soft, resilient, and sweet-smelling skin, smooth and uncharted, vulnerable but strong. Now they are in their late 20s, still very youthful, but starting to have a few wrinkles around their eyes, foreheads, and hands. They have not yet had children of their own, but I can imagine how transformative a pregnancy would be for each of them, as the skin is challenged to keep up with and contain the miraculous changes going on inside, while the body generates and ultimately releases new life into the world. I recently sat at the kitchen table in that small house on Long Island that my mother built those many years ago. My mother was there that weekend, as were both girls, and my wife. As we all sat eating breakfast at the table, my eyes passed from my mother’s wrinkles and bruises to my daughters’ young adult faces, and I imagined them as mothers and then grandmothers in their own right, with the history of what I hope will be their long and happy lives written into the texture of their own skin. I notice the back of my own hands, tanned from this summer’s sun, freckled more than usual, but also more wrinkled than I would have thought when I was younger, and I also notice some larger brown lentigines (which somehow now seems less harsh a term than “age spots”) that I don’t remember seeing before this year. Since my mid-50s, I’ve seen that the skin on the distal parts of my lower legs and arms has gotten thinner and more finely wrinkled, and I wonder sometimes when it might start to show some of the same changes I have seen in my mother’s skin over these past few years. (In an ambivalent response that seems to fluctuate between self-care and vanity, I have started to use moisturizing creams on these thinning-out areas. In our local chain pharmacy, I feel like I have entered a brave new world: the skin moisturizer aisle was one of which I had been
blissfully unaware for years, and now as I look down the long rows of skin rejuvenators, wrinkle smoothers, and a dizzying array of “antiaging” products, I realize it is not an accident that the fear of death has spawned such a multibillion-dollar marketplace. Imagine such products in a society where age and the wisdom of the elders were valued, even venerated, not dismissed or marginalized.) I am reminded how frequently the body sheds its skin, constantly making new layers, so that even the skin that I am seeing in myself and others around me is a symbol of transition, of constant change. And yet within that unending transformation, each age is clearly defined and demarcated by its own, as it were, skin. My dermatologist has an etching in her office with the title “The Skin Doesn’t Lie,” and I suppose this is true. It also seems to carry a lot of weight: physical attraction, eroticism, repulsion, hatred, all can be translated into responses to other people’s skin, its texture, configuration, color, which seems to give the lie to the adage about beauty being only skin deep. Being thick-skinned, feeling comfortable in my own skin, making my skin crawl: all of these seem to invest much meaning in our surface covering, that we take for granted until it loses its integrity. I flash back to my postcollege experience, spending a year before medical school working as a nursing assistant in the operating rooms at Massachusetts General Hospital, where I would watch as the surgeons painstakingly sheared off healthy skin from the unaffected limbs of burn survivors, pulling the elastic ribbons of skin off the bleeding base from where they had just been cut, and applying them like wallpaper to the raw, open areas lying exposed from the burns. I recall thinking how violated these patients’ bodies seemed to be, how their skin could no longer contain and protect them, could not effectively maintain the separation of inside from outside. With all her frailty, accumulated injuries, losses, and indignities, my mother is still getting up every day, living in her skin, making breakfast, reading the paper, taking care of what she can. Looking at her bruises and sores, I feel both uncomfortable and admiring of how intact she is as she heads past 92 and beyond. I hope my own skin can hold me together for that long too.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.
34
JAMA January 6, 2015 Volume 313, Number 1
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/06/2015
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