"I have a patient" my wife told me "who is 62 years old. She has white raised white lesion on the labia. It does not go away on wiping, feels firm and irregular. There is no pain or itching."
"It sounds like vulvar dystrophy" I said. "It will need to be biopsied. If there is vulvar intraepithelial neoplasia, she may require a simple vulvectomy."
"Vulvar dystrophy? Is that common?" she asked.
"No. I have not seen any patient in 35 years, despite the busy outpatient clinic."
"Then how do you know?" she asked.
"I have seen picturs of the condition" I said. "That is how I function. I keep the knowledge about rare conditions in my head ready, waiting for a case to turn up."
"Who shall I refer her to?" she asked. She was nice enough not to doubt my diagnosis based solely on her description, and despite not having seen a single patient.
"Send her to a dermatologist. Skin biopsy requires Keye's biopsy punch which dermatologists have, but gynecologists don't."
The patient was reluctant to go to a civic hospital. So she sent her to a dermatologist with a note saying that the patient had a vulvar dystrophy and would need a biopsy. The patient was send back by the dermatologist to my wife, with a note stating "the patient has a vulvar dystrophy and needs a biopsy."
My wife was surprised, and so was I when she told me about it. We could see no point in the specialist repeating what the family physician had written and sending the patient back. So my wife referred her to a gynec oncologist at a multispecialty starred hosppital nearby.
"They are willing to do the biopsy" she told me later. "But they are going to charge 28000 INR for it."
"28000 INR?" I was aghast. "That is too much for removing a tiny bit of skin under local anesthesia."
"They wanted 55000 INR. When she told them she was not well affording, they checked her bank passbook and finally lowered the price to 28000 INR after a great deal of haggling. She does not have that kind of money."
"Send her to my hospital" I said. "I will get it done."
I am proud to say our dermatologists performed the procedure the same day without any hassle and she went away happy. I am still wondering why the starred hospital wanted so much money, when it is required to treat 20% patients free, as per agreement with the civic body for getting various tax exemptions and land on nominal lease. Even if I write to the civic body, there will not be any change. I know it, because there has been a lot written on it in the newspapers, and still no improvement has taken place.
