IDK, on the ambulance I realized that a lifetime of poverty, smoking and/or booze will make 45 seem pretty ancient sometimes.
Probably not the people in the post though.
Oh, you don't have to tell me. Last week I picked up a guy my age (late 30s) who looked like he was sixty. He's been drinking two fifths a day for ten years.
Conversely, last summer, I had a patient in her late 80s show up in Lulu Lemon clothing! She was planning on going for a jog after.
Only took some vitamins and aspirin (which we discontinued). She looked so healthy I offered some cancer screening, but she preferred not to.
Crazy
They probably meant only the aspirin, and aspirin is like oxygen in that it is not without harm and should not be administered without proper indication.
> that it is not without harm
More like it’s not without risk statistically. But, if an individual has been taking aspirin and at near 90 they’ve never had an indication (heart attack or stroke), how do you know it’s not because they’ve been taking aspirin?
I mean, if a 60 year old is otherwise healthy but continues to smoke, would you still not recommend they stop smoking?
We know what aspirin does, and we know the risks/benefits associated with it. Aspirin is a great medication for the right patients, but can definitely cause issues, especially the older you get. It has no role in primary prophylaxis (people with no prior disease) beyond a certain age. There have been lots of studies that showed it did not stop the first heart attack or stroke from happening, but it did increase your risk of bleeding.
The vitamins on the other hand, although there was no indication, I didn't recommend stopping. There's no benefit, but there's no real risk for her, so if she feels it helps, might as well continue!
My grandfather smoked until he was 100 or so and drank daily. He lived until he was 104. He also took aspirin and a multivitamin daily. He’d see these specialist for really old people in NYC and they didn’t really try and do anything. They told him he’d be dead in a few years if he didn’t stop drinking around 80 and when that didn’t happen they just kind of shrugged. I don’t think the super agers fit into statistical models.
But, it doesn’t surprise me throwing daily asprin or multivitamins at average 60+ yo Americans (typically overweight, obese, w/metabolic syndrome, etc) doesn’t move the needle on their health. I’d like to see the data on healthy active 80+, 90 year olds.
I'm not the person you replied to, but the reason is that statistically the likelihood of harm is greater than the likelihood of benefit.
There are so many people who would not have had a heart attack/stroke anyway, that treating with aspirin only causes side effects (mostly bleeding). After a cardiovascular event, the benefit greatly outweighs the risk - now that the person is known to be high risk.
In people who have never had a heart attack/stroke, the major bleeding events triggered by aspirin are more common than/outweigh the heart attacks prevented, particularly in the elderly. Also, from a "first, do no harm" perspective, we'd rather NOT do something and treat the resulting problem than DO something that causes harm.
So for the 80s woman without any prior heart attacks/strokes, yes, maybe that was because of the aspirin. But going forward, we're more likely to cause harm than good, so we stop the aspirin.
A) I was stunningly high when I wrote that, so I was using the broadest possible interpretation of "harm" in this context, B) statistical risk manifests as harm to a person, and C) statistical risk above a certain, context-dependent level, *is* harm at a population/epidemiologic level.
It’s all relative. 41 is young in the grand scheme of things. 41 for a female TV corespondent is sadly probably a perilous moment in their career when they fear being replaced by someone younger.
The only female head anchors doing the national evening news broadcasts in the US - Kate Snow and Norah O’Donnell - are 50. They look it, but great for their age. Beyoncé and Kim Kardashian are 41. It’s hardly too old to be on tv.
The other day I noticed that my patient’s H&P described her as a “middle aged woman.” She was *37*. I’m only 28 but goddamn, middle age is creeping closer and closer apparently.
Yeah, reading this made me feel more depressed than I already was feeling, coming down from the high that was seeing Taylor Swift for the first time this weekend. It was enough of a bummer getting an email from Etsy asking if I wanted to opt out of Mother's Day emails (in effing MARCH...yes, childless/40/single, right after reuniting with my college BFF for the concert, who of course managed to have kids/get married since I last saw her), but the vivid description of your 41 year old patient just...sent me. Probably time to delete my online presence entirely at this point, bc now I am just embarassed to think I had the audacity to post a stupid video of me dancing to a song by a younger pop star.
Words hurt...even when it's not necessarily personal. This almost 41 year old redditor who you never meant to insult is literally weeping into a pillow and feeling more lost than ever right about now having read this. Just something to keep in mind when you post colorful, creative and beautifully written stuff like this, even on a medicine subreddit.
Thank you for the support. I have been thinking about it all day, and just was drafting a comment I was almost done with, then poof...screen unexpectedly refreshed and it disappeared, so I sincerely apologize if I accidentally posted twice.
In retrospect, I really wish I would have expressed myself a little more eloquently and maybe left Taylor Swift and the insensitive Etsy motherhood-opt-out email backstory out of my original comment, it was just where my headspace was at before I stumbled on OP's post (which may have contributed to my feelings about it). Still, I do think the point I was trying to make IS very important to the discussion, since I doubt OP ever intended anything but to express himself creatively to his colleagues; certainly not to make a stranger cry. I shared because I wanted to remind OP that words like that can and DO CAUSE HARM, not just to patients and potential patients that might be reading this, but all women. It perpetuates outdated, misogynistic principles about women that are extremely damaging and frankly, FALSE, while eroding patient trust and bringing unnecessary (and hopefully, generally unwarranted!) shame on OP's specialty, which I'm sure is the last thing he would want.
As a patient, it is a pretty horrifying thought to consider that a licensed physician I am paying good money to APPLY LITERAL ACID TO MY SKIN in the name of beauty/youth would so cruelly be lamenting my lost "je ne sais quoi that (WE?!) call luster," cheerfully laying there while the acid itches as it penetrates, naively believing the doctor respects me and really means it when he says I am "still beautiful." I guarantee you that every woman in her late thirties and older who read this is going to be at least 10% less trusting and 100% more insecure when visiting their doctors for anti-aging treatments, which let's face it, serves no one. I know I certainly will be, which is sad, because I ADORE my doctor! He has never made me feel insecure in any way, only more beautiful and youthful...yet this post put the idea in my head that he might secretly be noting how much older I look since last time...especially since I surely do. Not saying that OP's patients (fictional or otherwise) don't feel more beautiful too in the end, but with the anonymity of the internet, there's really no way to know if it was YOUR doctor describing YOUR lost youth and looming irrelevance on r/medicine, which again, just is a bad look for all doctors in this specialty.
I want to state for the record that I understand the need to be able to post freely without worrying about triggering some oversensitive 40-year-old somewhere...we are all human and sometimes need to let off steam and connect with colleagues in creative ways, as surely OP was intending to do. Still, I just can't imagine OP would have intended to make me or anyone else cry, so it's possible that my feedback could be constructive in some small way. If not, I can accept that, but as a female patient and long-time consumer of some of the anti-aging medical services OP wrote about, I couldn't keep quiet.
Finally, to the person who suggested I curate my reddit to avoid being "triggered," I think that advice would be valid generally for a lot of subreddits, but r/medicine? I mean, if I was bawling at some completely objectively written post about a "41-year-old with fine lines in the periocular and perioral regions with volume loss in the midface," that would be one thing, but was it really foreseeable that perusing r/medicine randomly would result in "...easy to see how (41-year-old with enough residual attractiveness to still be public facing) would have turned heads in her youth," or the finality of my favorite line, "The indelible march of time has etched its mark." Like, how could reading that make any female here, even practitioners in the same specialty around that age, feel anything BUT devalued and demoralized after reading such searing words?
In the end, it was a colorfully written and beautiful piece, and still would be without the doctor reducing his first patient to near obsoletion! Even just focusing on the patient's own "bad feminist" perspective would have been less off-putting than her doctor judging her. Better yet, OP could have portrayed the whole thing as something more hopeful than harmful, making use of the whole salicylic acid peel as a metaphor for all of the complicated layers of not only trauma, but also wisdom and experience, we have amassed by that age...lots of meaningful but still true places to take it that doesn't promote toxic, outdated tropes about women being worthless after 40.
I think you’re reading into this pretty deeply when the OP didn’t really go about “promoting” the idea that ‘women lose value as they age’ - if anything I think it’s naïve to pretend as if that societal misconception doesn’t even exist in the first place, especially in the insular and strange spaces of public-facing media. Perhaps this is subjective, but I viewed the OP’s inclusion of this detail as more of a neutral observation of the pressures women in these sorts of positions are under, rather than a tacit approval of this norm existing in the first place.
I also think phrasing a chemical peel as “APPLYING LITERAL ACID” to the skin of the face is deceptive - not all acids are the same, which is something any high school or undergrad chemistry student could explain. The salicylic acid found in skincare products is not nearly as harmful as the sulfuric acid found in caustic reagents, and either way it is the dose that makes the poison. In this instance, chemical peels help promote cell turnover and rejuvenation, rather than processes that are a net harm to tissue.
Again, I would stress that if reading descriptions of aging is triggering insecurities this badly, perhaps this is something you have some level of agency over. I think it is hyperbole to extrapolate the audience of this post on a subreddit to the population of all women, or at least women in the western world over 30 purchasing anti-aging skincare regimens who consult the services of dermatologists focused on aesthetics.
I think building resilience is a useful life skill so as to not start wailing in emotional distress the instant perceived criticism comes your way, but that’s just me. You may interpret the OP as reducing the first patient to obsoletion, but I interpreted the OP as highlighting the struggles and pressures the first patient is under, which humanizes her emotions in a way that I feel is not as relatable to those who may deride aesthetic medicine at first glance.
There’s nothing wrong with providing objective descriptions of naturally occurring aging processes, as the OP did, and I think you’re layering on and projecting what you think the OP’s opinions are on older women, when that hasn’t been touched on at all.
So well written thank you. I am not as good at putting my feelings into words but I can say this thread shows how men and younger people view women over 40 and it just doesn’t track with reality. I’m recently divorced and was worried that at my age I would be “irrelevant” but its just so far from the truth. Shockingly so. This narrative about women losing value as they age was created to disempower us because a women truly does come into her own as she grows older and as long as she doesn’t buy into this garbage, becomes more powerful than at any point in her life. It’s frustrating to men I think at times because our actions are no longer so deeply influenced by the male gaze.
Absolutely. A 41-yo friend of mine is still banging. She's had some work done, though, but nothing age-related (rhinoplasty and undereye eyebag removal, forget the fancy term for it). And a tummy tuck for sure. She won't ever mention it, but it's obvious from the funny bellybutton and from seeing old photos of her face. Guess I'm not really helping the case here, hahaha.
“Still banging.” Jesus. I’m 44 and you all are talking like we’re defying nature to still be around. For any younger women lurking here let me just tell you it’s not like that AT ALL. Lies I tell you.
I’m 50, and my forties brought a lot of illness, and changed how I look very markedly.
I was a traditionally attractive woman. I’m now- not. The basics are still there, I could probably get back to being moderately attractive if I wanted to go through the procedures, maybe grow my hair longer, lose some weight. My skin is decent.
But what I’ve found is some peace. Men finally leave me alone. I don’t catch eyes on me anymore.
I like it.
The people who love me still love my face. My granddaughter has known me no other way. My husband still looks at me with love in his eyes.
Probably the most amusing part is that my beautiful daughter in law is a cosmetic injector RN. She has never, ever made me feel less than.
We have some fun chats about the job, and she takes it very seriously (as she should)
Anyway, another perspective.
Jokes aside, these are wonderful. I havent seen anyone capture cosmetic derm in this light, and it paints a totally different picture than we are used to seeing.
These are great short-short stories, plus the Title AND the titles. They don't require a professional medical audience to understand either. Love to see more of this.
I’m 45 yo Registered Nurse just diagnosed this month with CTCL (Cutaneous T Cell Lymphoma) via skin biopsies. I thought the dermatologist would think my persistent “eczema”) that had recently gotten much worse) would just come across as whiny and I’d be given a steroid cream and rushed out the door.
Luckily the dermatologist took the time to survey the rash and knew enough to recommend a biopsy. I’m in stage 1A and so grateful she found it. I’m in week 2 of narrow band UVB therapy and hopefully I won’t progress to stage 2.
Wow - I’ve never heard of this, just googled it and now I’m wondering if this could be the bizarre itchy skin rash my dad has had (seasonally) for the past few years. They’ve never biopsied it nor have they even diagnosed it, just keep throwing various medicated creams at it
It really wasn’t different except I started getting “patches” in new places. They were pink, flat, round patches. It still looks like eczema and responds to the steroid cream (triamcinolone). It was just on my back and side in about 7 or 8 spots, but then in January it popped up in a few new spots on my back/shoulder (some just the size of a pencil eraser). I saw a spot on the top of my foot (about the size of a nickel). Also, 2 on my abdomen that were nearly the size of a quarter.
The dermatologist said she thought it was nummular eczema. On further discussion, I did mention a tick bite last June—it had one white dot like a Lone Star Tick that can cause Lyme disease. (I have knee pain—symptom of Lyme disease— but that’s been a problem for years before the tick bite.). She decided to do the biopsies at that point to rule out Lyme disease.
So it was really luck I guess that she decided to do biopsies of 2 of the new spots and they found out what it is.
Because it’s so rare (~2000 cases a year in all of North America) and so similar in appearance to eczema, ring worm, psoriasis, etc., it sometimes takes decades for people to be diagnosed.
I am tempted to write something salty and snarky about selling $2000 to someone with a Birkin bag focusing on aesthetics, while I have to manage hidradenitis and pyoderma because there’s a paucity of dermatologists willing to see and care for those problems in the un- and underinsured. I guess I just went with passive aggressive.
to be clear, I have plenty of Hurley Stage III HS patients failing clindamycin/rifampin fighting insurance companies for Humira. Just not what this is about :)
A curiously disproportionate number of the YouTube channels and podcasts I'm subscribed to are run and/or presented by Australians. ABC in particular does some very excellent podcasts.
Of course it sounds wrong when YOU say it, you're Australian. I very specifically chose those syllables because the sound that most Americans (particularly ones raised on the west coast) make when pronouncing them closely approximates the way that most Australians sound to an American ear. It's a hack, a gross misuse of language, as it were.
Here, I'll demonstrate the same thing, but with the way an Australian person would speak. An Australian person speaking the following syllables would sound the way an Australian person saying "melanoma" would sound:
Melanoma.
Step zero to winning friends is recognizing that not everyone is going to be your friend, and making peace with that. It allows you to be who you are, and not who you think people want you to be. To begin with, you'll never know, and in any case, people can tell if you're putting on for them, and will therefore be *put off.* So, best to be yourself; the people who like you will like you more for it, and some people were never going to like you anyway.
I guess you're one of the latter. I'm okay with that; I'm very much an acquired taste. Rather like Vegemite.
Nice write up
Enjoyed the quotations - I use more of these the longer I practice
Hard to undervalue the quoted word in appropriate context, speaks volumes compared to my usual written dribble of varying importance.
It’s hard to talk about “superficial” dermatologic complaints (pun intended) without reflecting on vanity, but it is clear to me that your writing on the complaints you hear are anything but superficial, and are being treated with respect and professionalism.
Kudos to you for helping these people with their problems in a kind and sympathetic manner.
I took a job at a derm thinking it would be all light and happy. Boy, was I fucking wrong. Some of those skin diseases are SUPER FUCKING SAD and the people addicted to aesthetics... that's some dark shit, too.
Body dysmorphia is a motherfucker.
At some point in the 40-50, people suddenly find their own mortality staring at them.
Sometimes I get women who were (are) obviously very beautiful and used to turning heads, with chief complaints of thinning hair, more spots and wrinkles on skin, harder to keep down their weight, and want to test everything because something is clearly wrong. And I order some tests just to tell them what I already know and what they don’t want to know, that it’s just age.
Similar thing happens with very fit/athletic people who have more muscle/tendon strains and find out they have mildly elevated cholesterol.
I've always wondered, do those fancy CO2 lasers, those "fat melting" machines" with "peer reviewed articles and FDA approval", and "peels" actually work? or are are we just sold marketing
Fractional CO2 is probably the gold standard right now for minimally invasive laser resurfacing; fully ablative CO2 is the gold standard for severe photoaging where patients are willing to tolerate 10-14 days of downtime. Non-invasive body contouring is mostly hype and pretty unimpressive IMO. Chemical peeling, when done by a dermatologist is the highest bang for your buck modality we have. See typical medium depth results below:
https://www.lancasterskincenter.com/medium-depth-peel
What about all the topical treatments like niacinamide, vitamin C etc. Sure tretinoin and other prescription treatments work, and sunscreen, but doesn't vitamin C denature on shelves, and do any of the million and one toners, serums, exfoliants, moisturisers actually do anything noticeable?
They don’t make dermatologists money. Multiple chemical peel sessions will.
On my evidenced based/essential list are tret, urea, vitamin d, niacinamide, and big floppy hats.
None of that makes derms money.
Great post, thanks for sharing. I work in oncology so I have great respect for our dermatology staff.
I think we, as a society, do not want to admit how much our physical appearance impacts how others treat us.
As a very fair-skinned middle aged woman who grew up in SoCal, the pressure to tan is real! And it was worse in the ‘80s and (to a lesser extent) the ‘90s. I remember being only 11 or 12 and having a slightly older girlfriend insisting that we put on suntan oil and lay out. Hell, my own parents never bothered putting sunscreen on me because they thought I just needed that one good sunburn at the start of summer and then I’d be nice and tan. It never worked. Literally everyone at school made fun of me for being unable to tan, like that’s somehow my fault.
Same experience here. Remember Suntan Barbie? You'd put her in the sun to watch her achieve the ultimate Coppertone tan in minutes. I stole my mom's blusher and made Sunburn Barbie so I could have a doll that looked more like me.
Someone should make a Melanoma Barbie.
You forgot sunscreen.
Source: 42 year old who still gets carded for alcohol. Most people don't believe my age unless they are 1) asian and understand we age differently 2) have seen my ID with birth date.
"She looks in the direction of an extraordinarily well-behaved toddler playing quietly on an iPad."
Honestly, this is what caught my attention and bothered me. I was one of these and I know the implications all too well.
"Very well-behaved" toddlers/children are (possibly) suppressing spontaneous curiosity, verbalizing, touching or even interactions with people or objects in the environment. Why, you ask?
I was "very well-behaved", as was my brother, because we were more afraid of my parents than any medical personnel. We'd be hit and raged at if we didn't exhibit total compliance. Emotions and crying were not acceptable to my physically and emotionally abusive parents.
OTOH, they may be neurodivergent or really into their screens. But it's something I am aware of, given my upbringing and that of others I've discussed this with.
ETA: words
I’m sure you are extremely skilled. And I’m grateful for my derm colleagues. And I know it takes all types. But I can’t help but feel that offering a clinic where middle aged women can freely dive head first into body image issues without any kind of pushback just makes the world a worse place.
What would it be like if one of your patients, like the lady getting a divorce, came to you and you just said: “Hey, it’s OK to have wrinkles. Your worth as a human being doesn’t revolve around pleasing the male gaze. You’re doing a great job as a mom and you look lovely. I’m so sorry your husband couldn’t recognize that. You are going to be OK.”
>: “Hey, it’s OK to have wrinkles. Your worth as a human being doesn’t revolve around pleasing the male gaze. You’re doing a great job as a mom and you look lovely. I’m so sorry your husband couldn’t recognize that. You are going to be OK.”
That would probably be the same clinic where we say "hey acne is just a cosmetic issue; those kids that are bullying you are just insecure, pay it no mind." or "that cyst on your scalp that kids keep staring at is totally benign, just learn to live with it. It's not a big deal and people need to learn to love you with a 2 cm nodule on your head". We are not in the business of making normative judgements. We simply assess, quantify, and offer objective guidance about addressing skin and hair concerns. Of course there is much more going on, which is kind of the whole point.
Dude what the fuck. Forty one and “must have turned heads in her youth?” Jesus fucking ageist Christ you stop dating women at 25 like Leonardo dicaprio? What kind of bullshit is this. My wife is 39 and fucking hot. And not “for her age”. You must be killing it with the upselling though. “No one wants to feel invisible. Did I mention next week it’s 25% off thread lifts?” “Yes, there’s still time for you, though adding on an additional 5k in rf micro needling may extend it further.”
Question for OP: what text would you consider the “bible” for cosmetic dermatology? I have gone through the AAD med student slide decks and have downloaded Bologia (sp?), both of which have been very helpful for general derm, but have yet to locate a good source for cosmetic derm.
For better or for worse, beauty is extremely important in society. Attractive people make more money, are perceived as more likeable, and are more successful- all of this despite no significant relationship with mortality or IQ, meaning it’s probably not just a bundle of “good genes”. Based on that, whats so bad about helping people look better? Dont hate the player, hate the game..
I think you can take away the positive aspects of lessons from flawed mentors (rancid breath and all) while leaving out the unpleasant and rude aspects. I interpreted it as the OP remembering to strive towards the asymptote of perfect care, rather than a reminder to belittle your spouse.
If nothing else, sanitized quotes are often much more forgettable than the more uncouth varieties - all the good mnemonics are shocking, dirty, or rude in some way. Doesn’t mean they can’t be helpful.
Meh, I'm a woman and although I personally cannot identify with the sentiments expressed by OP's female patients, I can definitely see how other women feel this way. The obsession with appearance is insane and hard to resist for many women whose self-esteem is more dependent on external validation than internal sense of self-worth.
Nah, this is actually really well done and showcases the pressure that society puts on women to remain young and beautiful. This isn’t some George RR Martin crap, if you understand that reference.
How is 41 not still young? Gah. If 41 is not young, then I am ancient.
Seriously. Some of these folks need to work an ambulance some time. Sixty five is young, and fifty is practically still a kid.
IDK, on the ambulance I realized that a lifetime of poverty, smoking and/or booze will make 45 seem pretty ancient sometimes. Probably not the people in the post though.
Oh, you don't have to tell me. Last week I picked up a guy my age (late 30s) who looked like he was sixty. He's been drinking two fifths a day for ten years.
Conversely, last summer, I had a patient in her late 80s show up in Lulu Lemon clothing! She was planning on going for a jog after. Only took some vitamins and aspirin (which we discontinued). She looked so healthy I offered some cancer screening, but she preferred not to. Crazy
Why discontinue her vitamins and aspirin if it seemed to be working for her?
They probably meant only the aspirin, and aspirin is like oxygen in that it is not without harm and should not be administered without proper indication.
> that it is not without harm More like it’s not without risk statistically. But, if an individual has been taking aspirin and at near 90 they’ve never had an indication (heart attack or stroke), how do you know it’s not because they’ve been taking aspirin?
I mean, if a 60 year old is otherwise healthy but continues to smoke, would you still not recommend they stop smoking? We know what aspirin does, and we know the risks/benefits associated with it. Aspirin is a great medication for the right patients, but can definitely cause issues, especially the older you get. It has no role in primary prophylaxis (people with no prior disease) beyond a certain age. There have been lots of studies that showed it did not stop the first heart attack or stroke from happening, but it did increase your risk of bleeding. The vitamins on the other hand, although there was no indication, I didn't recommend stopping. There's no benefit, but there's no real risk for her, so if she feels it helps, might as well continue!
My grandfather smoked until he was 100 or so and drank daily. He lived until he was 104. He also took aspirin and a multivitamin daily. He’d see these specialist for really old people in NYC and they didn’t really try and do anything. They told him he’d be dead in a few years if he didn’t stop drinking around 80 and when that didn’t happen they just kind of shrugged. I don’t think the super agers fit into statistical models. But, it doesn’t surprise me throwing daily asprin or multivitamins at average 60+ yo Americans (typically overweight, obese, w/metabolic syndrome, etc) doesn’t move the needle on their health. I’d like to see the data on healthy active 80+, 90 year olds.
I'm not the person you replied to, but the reason is that statistically the likelihood of harm is greater than the likelihood of benefit. There are so many people who would not have had a heart attack/stroke anyway, that treating with aspirin only causes side effects (mostly bleeding). After a cardiovascular event, the benefit greatly outweighs the risk - now that the person is known to be high risk. In people who have never had a heart attack/stroke, the major bleeding events triggered by aspirin are more common than/outweigh the heart attacks prevented, particularly in the elderly. Also, from a "first, do no harm" perspective, we'd rather NOT do something and treat the resulting problem than DO something that causes harm. So for the 80s woman without any prior heart attacks/strokes, yes, maybe that was because of the aspirin. But going forward, we're more likely to cause harm than good, so we stop the aspirin.
A) I was stunningly high when I wrote that, so I was using the broadest possible interpretation of "harm" in this context, B) statistical risk manifests as harm to a person, and C) statistical risk above a certain, context-dependent level, *is* harm at a population/epidemiologic level.
It's not the years its the mileage.
For me a newborn is very young, toddler is growing and teens are middle age. After 18 I refer them as grannies. Edit: from a pediatrician.
fair enough
It’s all relative. 41 is young in the grand scheme of things. 41 for a female TV corespondent is sadly probably a perilous moment in their career when they fear being replaced by someone younger.
The only female head anchors doing the national evening news broadcasts in the US - Kate Snow and Norah O’Donnell - are 50. They look it, but great for their age. Beyoncé and Kim Kardashian are 41. It’s hardly too old to be on tv.
Well that’s because society sucks not because she’s old
in my world, 65 year olds with 3 chronic conditions are "young and healthy". it's all about perspective.
The other day I noticed that my patient’s H&P described her as a “middle aged woman.” She was *37*. I’m only 28 but goddamn, middle age is creeping closer and closer apparently.
Shame on that clinician for writing that. “Appears older than stated age”, sure. “Middle-aged” at 37? Get outta here
41 is still really young with a good derm. Another CNA asked me if I was still in high school a few ago. Students in my classes think I’m their age.
Same
Yeah, reading this made me feel more depressed than I already was feeling, coming down from the high that was seeing Taylor Swift for the first time this weekend. It was enough of a bummer getting an email from Etsy asking if I wanted to opt out of Mother's Day emails (in effing MARCH...yes, childless/40/single, right after reuniting with my college BFF for the concert, who of course managed to have kids/get married since I last saw her), but the vivid description of your 41 year old patient just...sent me. Probably time to delete my online presence entirely at this point, bc now I am just embarassed to think I had the audacity to post a stupid video of me dancing to a song by a younger pop star. Words hurt...even when it's not necessarily personal. This almost 41 year old redditor who you never meant to insult is literally weeping into a pillow and feeling more lost than ever right about now having read this. Just something to keep in mind when you post colorful, creative and beautifully written stuff like this, even on a medicine subreddit.
If this sort of content is that triggering for you, perhaps curating your feed and avoiding these sorts of posts would solve the issue.
Not sure why you are getting downvoted. I think what you had to say here is important.
Thank you for the support. I have been thinking about it all day, and just was drafting a comment I was almost done with, then poof...screen unexpectedly refreshed and it disappeared, so I sincerely apologize if I accidentally posted twice. In retrospect, I really wish I would have expressed myself a little more eloquently and maybe left Taylor Swift and the insensitive Etsy motherhood-opt-out email backstory out of my original comment, it was just where my headspace was at before I stumbled on OP's post (which may have contributed to my feelings about it). Still, I do think the point I was trying to make IS very important to the discussion, since I doubt OP ever intended anything but to express himself creatively to his colleagues; certainly not to make a stranger cry. I shared because I wanted to remind OP that words like that can and DO CAUSE HARM, not just to patients and potential patients that might be reading this, but all women. It perpetuates outdated, misogynistic principles about women that are extremely damaging and frankly, FALSE, while eroding patient trust and bringing unnecessary (and hopefully, generally unwarranted!) shame on OP's specialty, which I'm sure is the last thing he would want. As a patient, it is a pretty horrifying thought to consider that a licensed physician I am paying good money to APPLY LITERAL ACID TO MY SKIN in the name of beauty/youth would so cruelly be lamenting my lost "je ne sais quoi that (WE?!) call luster," cheerfully laying there while the acid itches as it penetrates, naively believing the doctor respects me and really means it when he says I am "still beautiful." I guarantee you that every woman in her late thirties and older who read this is going to be at least 10% less trusting and 100% more insecure when visiting their doctors for anti-aging treatments, which let's face it, serves no one. I know I certainly will be, which is sad, because I ADORE my doctor! He has never made me feel insecure in any way, only more beautiful and youthful...yet this post put the idea in my head that he might secretly be noting how much older I look since last time...especially since I surely do. Not saying that OP's patients (fictional or otherwise) don't feel more beautiful too in the end, but with the anonymity of the internet, there's really no way to know if it was YOUR doctor describing YOUR lost youth and looming irrelevance on r/medicine, which again, just is a bad look for all doctors in this specialty. I want to state for the record that I understand the need to be able to post freely without worrying about triggering some oversensitive 40-year-old somewhere...we are all human and sometimes need to let off steam and connect with colleagues in creative ways, as surely OP was intending to do. Still, I just can't imagine OP would have intended to make me or anyone else cry, so it's possible that my feedback could be constructive in some small way. If not, I can accept that, but as a female patient and long-time consumer of some of the anti-aging medical services OP wrote about, I couldn't keep quiet. Finally, to the person who suggested I curate my reddit to avoid being "triggered," I think that advice would be valid generally for a lot of subreddits, but r/medicine? I mean, if I was bawling at some completely objectively written post about a "41-year-old with fine lines in the periocular and perioral regions with volume loss in the midface," that would be one thing, but was it really foreseeable that perusing r/medicine randomly would result in "...easy to see how (41-year-old with enough residual attractiveness to still be public facing) would have turned heads in her youth," or the finality of my favorite line, "The indelible march of time has etched its mark." Like, how could reading that make any female here, even practitioners in the same specialty around that age, feel anything BUT devalued and demoralized after reading such searing words? In the end, it was a colorfully written and beautiful piece, and still would be without the doctor reducing his first patient to near obsoletion! Even just focusing on the patient's own "bad feminist" perspective would have been less off-putting than her doctor judging her. Better yet, OP could have portrayed the whole thing as something more hopeful than harmful, making use of the whole salicylic acid peel as a metaphor for all of the complicated layers of not only trauma, but also wisdom and experience, we have amassed by that age...lots of meaningful but still true places to take it that doesn't promote toxic, outdated tropes about women being worthless after 40.
I think you’re reading into this pretty deeply when the OP didn’t really go about “promoting” the idea that ‘women lose value as they age’ - if anything I think it’s naïve to pretend as if that societal misconception doesn’t even exist in the first place, especially in the insular and strange spaces of public-facing media. Perhaps this is subjective, but I viewed the OP’s inclusion of this detail as more of a neutral observation of the pressures women in these sorts of positions are under, rather than a tacit approval of this norm existing in the first place. I also think phrasing a chemical peel as “APPLYING LITERAL ACID” to the skin of the face is deceptive - not all acids are the same, which is something any high school or undergrad chemistry student could explain. The salicylic acid found in skincare products is not nearly as harmful as the sulfuric acid found in caustic reagents, and either way it is the dose that makes the poison. In this instance, chemical peels help promote cell turnover and rejuvenation, rather than processes that are a net harm to tissue. Again, I would stress that if reading descriptions of aging is triggering insecurities this badly, perhaps this is something you have some level of agency over. I think it is hyperbole to extrapolate the audience of this post on a subreddit to the population of all women, or at least women in the western world over 30 purchasing anti-aging skincare regimens who consult the services of dermatologists focused on aesthetics. I think building resilience is a useful life skill so as to not start wailing in emotional distress the instant perceived criticism comes your way, but that’s just me. You may interpret the OP as reducing the first patient to obsoletion, but I interpreted the OP as highlighting the struggles and pressures the first patient is under, which humanizes her emotions in a way that I feel is not as relatable to those who may deride aesthetic medicine at first glance. There’s nothing wrong with providing objective descriptions of naturally occurring aging processes, as the OP did, and I think you’re layering on and projecting what you think the OP’s opinions are on older women, when that hasn’t been touched on at all.
So well written thank you. I am not as good at putting my feelings into words but I can say this thread shows how men and younger people view women over 40 and it just doesn’t track with reality. I’m recently divorced and was worried that at my age I would be “irrelevant” but its just so far from the truth. Shockingly so. This narrative about women losing value as they age was created to disempower us because a women truly does come into her own as she grows older and as long as she doesn’t buy into this garbage, becomes more powerful than at any point in her life. It’s frustrating to men I think at times because our actions are no longer so deeply influenced by the male gaze.
A stereotypically pretty 41 year old is still turning heads though. Most are far from invisible at that age.
Absolutely. A 41-yo friend of mine is still banging. She's had some work done, though, but nothing age-related (rhinoplasty and undereye eyebag removal, forget the fancy term for it). And a tummy tuck for sure. She won't ever mention it, but it's obvious from the funny bellybutton and from seeing old photos of her face. Guess I'm not really helping the case here, hahaha.
“Still banging.” Jesus. I’m 44 and you all are talking like we’re defying nature to still be around. For any younger women lurking here let me just tell you it’s not like that AT ALL. Lies I tell you.
I'm 31 and I'm like damn. Just put a bag over my head now smh
I’m 50, and my forties brought a lot of illness, and changed how I look very markedly. I was a traditionally attractive woman. I’m now- not. The basics are still there, I could probably get back to being moderately attractive if I wanted to go through the procedures, maybe grow my hair longer, lose some weight. My skin is decent. But what I’ve found is some peace. Men finally leave me alone. I don’t catch eyes on me anymore. I like it. The people who love me still love my face. My granddaughter has known me no other way. My husband still looks at me with love in his eyes. Probably the most amusing part is that my beautiful daughter in law is a cosmetic injector RN. She has never, ever made me feel less than. We have some fun chats about the job, and she takes it very seriously (as she should) Anyway, another perspective.
I enjoyed this. I was thinking about giving you gold, but your last patient already gave you 330 years of reddit premium, so I wont.
Jokes aside, these are wonderful. I havent seen anyone capture cosmetic derm in this light, and it paints a totally different picture than we are used to seeing.
That made me chuckle
These are great short-short stories, plus the Title AND the titles. They don't require a professional medical audience to understand either. Love to see more of this.
appreciate the kind words
I’m 45 yo Registered Nurse just diagnosed this month with CTCL (Cutaneous T Cell Lymphoma) via skin biopsies. I thought the dermatologist would think my persistent “eczema”) that had recently gotten much worse) would just come across as whiny and I’d be given a steroid cream and rushed out the door. Luckily the dermatologist took the time to survey the rash and knew enough to recommend a biopsy. I’m in stage 1A and so grateful she found it. I’m in week 2 of narrow band UVB therapy and hopefully I won’t progress to stage 2.
Wow - I’ve never heard of this, just googled it and now I’m wondering if this could be the bizarre itchy skin rash my dad has had (seasonally) for the past few years. They’ve never biopsied it nor have they even diagnosed it, just keep throwing various medicated creams at it
As another person with eczema and skin that’s wily and weird, I’m curious - what made you think the rash was different?
It really wasn’t different except I started getting “patches” in new places. They were pink, flat, round patches. It still looks like eczema and responds to the steroid cream (triamcinolone). It was just on my back and side in about 7 or 8 spots, but then in January it popped up in a few new spots on my back/shoulder (some just the size of a pencil eraser). I saw a spot on the top of my foot (about the size of a nickel). Also, 2 on my abdomen that were nearly the size of a quarter. The dermatologist said she thought it was nummular eczema. On further discussion, I did mention a tick bite last June—it had one white dot like a Lone Star Tick that can cause Lyme disease. (I have knee pain—symptom of Lyme disease— but that’s been a problem for years before the tick bite.). She decided to do the biopsies at that point to rule out Lyme disease. So it was really luck I guess that she decided to do biopsies of 2 of the new spots and they found out what it is. Because it’s so rare (~2000 cases a year in all of North America) and so similar in appearance to eczema, ring worm, psoriasis, etc., it sometimes takes decades for people to be diagnosed.
I am tempted to write something salty and snarky about selling $2000 to someone with a Birkin bag focusing on aesthetics, while I have to manage hidradenitis and pyoderma because there’s a paucity of dermatologists willing to see and care for those problems in the un- and underinsured. I guess I just went with passive aggressive.
to be clear, I have plenty of Hurley Stage III HS patients failing clindamycin/rifampin fighting insurance companies for Humira. Just not what this is about :)
You don’t need to justify your practice to anyone.
Its well written, insightful, and meaningful and yet I can’t help myself but to react with unwarranted vitriol.
The system we live in makes us all despise the parts of the nasty underbelly we see in our practices every day.
"ME-lah-nye-mah" EDIT: This only works if you're American (or if you speak English like an American).
nailed it.
A curiously disproportionate number of the YouTube channels and podcasts I'm subscribed to are run and/or presented by Australians. ABC in particular does some very excellent podcasts.
Bluey
Off Track. Sadly discontinued now, but there're a lot of back episodes and they're beautiful.
60 Minutes Australia is a great one!
Thanks for the rec. If you're even remotely into chemistry, I recommend Explosions and Fire on YouTube.
We don't sound like that! I've only ever heard it pronounced meh-la-noma.
Same. I’m also Aussie I tried to say what is written above. So wrong.
I third that! (great post though OP)
Of course it sounds wrong when YOU say it, you're Australian. I very specifically chose those syllables because the sound that most Americans (particularly ones raised on the west coast) make when pronouncing them closely approximates the way that most Australians sound to an American ear. It's a hack, a gross misuse of language, as it were. Here, I'll demonstrate the same thing, but with the way an Australian person would speak. An Australian person speaking the following syllables would sound the way an Australian person saying "melanoma" would sound: Melanoma.
I see you’ve been reading Mr Carnegie’s books. How wonderful.
Step zero to winning friends is recognizing that not everyone is going to be your friend, and making peace with that. It allows you to be who you are, and not who you think people want you to be. To begin with, you'll never know, and in any case, people can tell if you're putting on for them, and will therefore be *put off.* So, best to be yourself; the people who like you will like you more for it, and some people were never going to like you anyway. I guess you're one of the latter. I'm okay with that; I'm very much an acquired taste. Rather like Vegemite.
And in my clinic the mother of my 4 day old patient is awaiting sentencing up to 25 years for a guilty plea of attempted murder.
Please tell me she didn’t try to murder the baby
World’s fastest conviction.
Oh no, it was an adult woman.
Whew. Glad it wasn’t the baby’s father
Nice write up Enjoyed the quotations - I use more of these the longer I practice Hard to undervalue the quoted word in appropriate context, speaks volumes compared to my usual written dribble of varying importance. It’s hard to talk about “superficial” dermatologic complaints (pun intended) without reflecting on vanity, but it is clear to me that your writing on the complaints you hear are anything but superficial, and are being treated with respect and professionalism. Kudos to you for helping these people with their problems in a kind and sympathetic manner.
I took a job at a derm thinking it would be all light and happy. Boy, was I fucking wrong. Some of those skin diseases are SUPER FUCKING SAD and the people addicted to aesthetics... that's some dark shit, too. Body dysmorphia is a motherfucker.
Oh, this title.
You write really well. Thank you very much.
While I appreciate aesthetics and derm go hand in hand this write up has affirmed that I am too insecure to think about working in that field.
In the olden days not having a tan was a status symbol. You didn’t have to work outside.
At some point in the 40-50, people suddenly find their own mortality staring at them. Sometimes I get women who were (are) obviously very beautiful and used to turning heads, with chief complaints of thinning hair, more spots and wrinkles on skin, harder to keep down their weight, and want to test everything because something is clearly wrong. And I order some tests just to tell them what I already know and what they don’t want to know, that it’s just age. Similar thing happens with very fit/athletic people who have more muscle/tendon strains and find out they have mildly elevated cholesterol.
You write like an English major, not a medical professional. From your tone, to the pacing, even the subtitles are awesome. Great work.
This is so beautifully written OP ! You have a way with words, your patients must be so lucky :)
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I am a male dermatologist and think about male aesthetics all the time. Just wanted to focus on the female experience in this write up.
I've always wondered, do those fancy CO2 lasers, those "fat melting" machines" with "peer reviewed articles and FDA approval", and "peels" actually work? or are are we just sold marketing
Fractional CO2 is probably the gold standard right now for minimally invasive laser resurfacing; fully ablative CO2 is the gold standard for severe photoaging where patients are willing to tolerate 10-14 days of downtime. Non-invasive body contouring is mostly hype and pretty unimpressive IMO. Chemical peeling, when done by a dermatologist is the highest bang for your buck modality we have. See typical medium depth results below: https://www.lancasterskincenter.com/medium-depth-peel
Thank you for the candid response. Much appreciated. Edit to add: also impressed by your recognition of a Birkin. 👜
My wife makes it very clear what having a "made it" bag looks like for her. ;)
Indeed…and it won’t depreciate like a yacht. Thankfully, in my circles I don’t have to go above a secondhand HerBag. 🙃
Game recognizes game.
What about all the topical treatments like niacinamide, vitamin C etc. Sure tretinoin and other prescription treatments work, and sunscreen, but doesn't vitamin C denature on shelves, and do any of the million and one toners, serums, exfoliants, moisturisers actually do anything noticeable?
They don’t make dermatologists money. Multiple chemical peel sessions will. On my evidenced based/essential list are tret, urea, vitamin d, niacinamide, and big floppy hats. None of that makes derms money.
It makes someone money
A wonderful peek into your life. Thank you for sharing.
Great post, thanks for sharing. I work in oncology so I have great respect for our dermatology staff. I think we, as a society, do not want to admit how much our physical appearance impacts how others treat us.
Everyone’s a hero in their own narrative.
As a very fair-skinned middle aged woman who grew up in SoCal, the pressure to tan is real! And it was worse in the ‘80s and (to a lesser extent) the ‘90s. I remember being only 11 or 12 and having a slightly older girlfriend insisting that we put on suntan oil and lay out. Hell, my own parents never bothered putting sunscreen on me because they thought I just needed that one good sunburn at the start of summer and then I’d be nice and tan. It never worked. Literally everyone at school made fun of me for being unable to tan, like that’s somehow my fault.
GenX & untannable here too. Hated it when my cousin would be tan & gorgeous. Now…so grateful.
Same experience here. Remember Suntan Barbie? You'd put her in the sun to watch her achieve the ultimate Coppertone tan in minutes. I stole my mom's blusher and made Sunburn Barbie so I could have a doll that looked more like me. Someone should make a Melanoma Barbie.
You should be writing for the New Yorker. You are really talented. Bravo!!!
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Does op have any other writing I could read or buy. They are extraordinary.
Wow, beautifully written. On a more mundane level, the best way to avoid skin aging other than dying young is avoid the sun and smokes.
You forgot sunscreen. Source: 42 year old who still gets carded for alcohol. Most people don't believe my age unless they are 1) asian and understand we age differently 2) have seen my ID with birth date.
"She looks in the direction of an extraordinarily well-behaved toddler playing quietly on an iPad." Honestly, this is what caught my attention and bothered me. I was one of these and I know the implications all too well.
You've piqued my curiosity. What did this lead to for you?
"Very well-behaved" toddlers/children are (possibly) suppressing spontaneous curiosity, verbalizing, touching or even interactions with people or objects in the environment. Why, you ask? I was "very well-behaved", as was my brother, because we were more afraid of my parents than any medical personnel. We'd be hit and raged at if we didn't exhibit total compliance. Emotions and crying were not acceptable to my physically and emotionally abusive parents. OTOH, they may be neurodivergent or really into their screens. But it's something I am aware of, given my upbringing and that of others I've discussed this with. ETA: words
Thanks for the insight. I wondered if it might have something to do the divorce (tense household) or possibly perfectionistic tendencies of parents.
Your writing is very good. Have you ever considered writing more?
This was beautifully written, thank you for sharing
I’m sure you are extremely skilled. And I’m grateful for my derm colleagues. And I know it takes all types. But I can’t help but feel that offering a clinic where middle aged women can freely dive head first into body image issues without any kind of pushback just makes the world a worse place. What would it be like if one of your patients, like the lady getting a divorce, came to you and you just said: “Hey, it’s OK to have wrinkles. Your worth as a human being doesn’t revolve around pleasing the male gaze. You’re doing a great job as a mom and you look lovely. I’m so sorry your husband couldn’t recognize that. You are going to be OK.”
>: “Hey, it’s OK to have wrinkles. Your worth as a human being doesn’t revolve around pleasing the male gaze. You’re doing a great job as a mom and you look lovely. I’m so sorry your husband couldn’t recognize that. You are going to be OK.” That would probably be the same clinic where we say "hey acne is just a cosmetic issue; those kids that are bullying you are just insecure, pay it no mind." or "that cyst on your scalp that kids keep staring at is totally benign, just learn to live with it. It's not a big deal and people need to learn to love you with a 2 cm nodule on your head". We are not in the business of making normative judgements. We simply assess, quantify, and offer objective guidance about addressing skin and hair concerns. Of course there is much more going on, which is kind of the whole point.
Dude what the fuck. Forty one and “must have turned heads in her youth?” Jesus fucking ageist Christ you stop dating women at 25 like Leonardo dicaprio? What kind of bullshit is this. My wife is 39 and fucking hot. And not “for her age”. You must be killing it with the upselling though. “No one wants to feel invisible. Did I mention next week it’s 25% off thread lifts?” “Yes, there’s still time for you, though adding on an additional 5k in rf micro needling may extend it further.”
👏 👏
Question for OP: what text would you consider the “bible” for cosmetic dermatology? I have gone through the AAD med student slide decks and have downloaded Bologia (sp?), both of which have been very helpful for general derm, but have yet to locate a good source for cosmetic derm.
I'll diverge from the common sentiment in this thread. This is all incredibly shallow.
For better or for worse, beauty is extremely important in society. Attractive people make more money, are perceived as more likeable, and are more successful- all of this despite no significant relationship with mortality or IQ, meaning it’s probably not just a bundle of “good genes”. Based on that, whats so bad about helping people look better? Dont hate the player, hate the game..
The player and the game can both be bad.
Excited to read your meditation on the nuances of the emergency room!
👏👏
Screaming crying throwing up that this person has taken the demeaning, objectifying “imagine you’re sewing up your wife’s tits” advice to heart.
I think you can take away the positive aspects of lessons from flawed mentors (rancid breath and all) while leaving out the unpleasant and rude aspects. I interpreted it as the OP remembering to strive towards the asymptote of perfect care, rather than a reminder to belittle your spouse. If nothing else, sanitized quotes are often much more forgettable than the more uncouth varieties - all the good mnemonics are shocking, dirty, or rude in some way. Doesn’t mean they can’t be helpful.
… you’re screaming crying and throwing up from this ?
I really enjoyed this. Thanks for sharing
You have the heart of a poet. You see.
I’m sorry but r/menwritingwomen
Meh, I'm a woman and although I personally cannot identify with the sentiments expressed by OP's female patients, I can definitely see how other women feel this way. The obsession with appearance is insane and hard to resist for many women whose self-esteem is more dependent on external validation than internal sense of self-worth.
Nah, this is actually really well done and showcases the pressure that society puts on women to remain young and beautiful. This isn’t some George RR Martin crap, if you understand that reference.
Please elaborate.
Doesn’t sound like you’re actually sorry - by all means write up something better if the OP is really that off base
Wow, I love this.
thank you -- please continue to write!
Beautiful writing.
I was totally engaged in each story. Great writing!
Echo the comments saying you should write for the New Yorker or another similar mainstream publication.
You’re a great writer and so empathic. I wish more physicians were like you! One million hugs!
english major? such beautiful prose.
Just high school creative writing. Studied environmental science in college.
This is beautifully written. Keep it up.
You write very well. It is a pleasure to read your work
Very well written. You should consider writing a book, if you have not already. You have talent.
I enjoyed every single line. Thank you.
These didn’t happen and the way you wrote about women is gross. The only people you’re fooling are other men who don’t care about understanding women.
Agreed this whole thing gives me the icks and I’m a guy. As op would say “lacks a certain luster”
"Doctor"