I thank my sweet daughter Julie for teaching me this very important lesson.

This past fall I watched my oldest child step onto the school bus for the first time and head off to kindergarten. My wife and I tried our best to reassure our daughter that she would make new friends, learn new things, have fun, and be just fine. Yet, I could not shake the uneasy feeling that she might not be "just fine." Had I done enough as a parent to prepare her for this big step? It was hard to let go for the first time.

This experience caused me to reflect on a similar work related situation that some of us have encountered while precepting PA students. We spend time training our PA students only to turn around and send them off to their next rotation, leaving us to wonder if we have given them enough education, information, and tools to succeed. I believe our apprehension is not due to a lack of confidence in their abilities, but rather due to our lack of assurance that we have done everything possible to prepare them. It is an awesome responsibility to be the one to take off the proverbial training wheels and let the students ride off on their own. Just like parents, we need to have confidence that we have helped them develop the skills, tools, and self-assurance that they will need to find their own way as they move on with their training and eventually become practicing PAs.

A twenty-one year-old "man" (you have to understand, at sixty-three I have shoes older than him) comes in with barely perceptible tiny oblong soft papules on his trunk, which disappear when the skin is stretched. Taking the end of a cotton-tipped applicator (the wooden end), and pressing down, they press in easily. This is consistent with a condition called anetoderma, which means that the elastic fibers in the dermis have been focally destroyed, allowing the subcutaneous fat to protrude through.

It's the first case of it I've ever seen, but I have seen images of it in texts for years, so I was ready. I did have to look it up and discovered that there are several types, loosely grouped under primary and secondary. Clearly, the patient belongs in the primary category, since he didn't have any antecedent lesions and has no symptoms. His type is called Schwenniger-Buzzi. I did draw an ANA and RPR, the former because lupus can trigger anetoderma, as can secondary syphilis,

Derm is like that, though. You have to keep reading about the unusual, and rare problems, because someday, here they will be. True, we could have biopsied and discovered the diagnosis, but it's much more fun to simply know what's going on. The patient's PCP had called the bumps "warts," since that was all he could come up with, which demonstrates the concept that you won't know that a biopsy is even indicated if you don't have some idea of what you're dealing with, and what it isn't.