Sunday morning. I was rounding leisurely with my residents. We moved as a group to the patient’s bedside in our ICU and saw several patients: a middle-aged woman with acute myocardial infarction, a boy heavily parasitized with plasmodium falciparum and a young man fighting a dual attack of HIV and TB. We looked at their monitoring sheets, browsed through laboratory test results and revised our management plans.

We approached bed 7. Our patient was in her twenties with a feeding tube in her nose, an indwelling cannula in her vein and a catheter in her urinary bladder. Her face, arms, palms, legs, soles and torso were covered with blisters, most of them drying. Her mucous membranes- ocular, oral and genital- were ulcerated and crusted.

My residents correctly assigned her a diagnosis of Stevens Johnson syndrome – a life threatening skin disease in which cells rapidly die causing epidermis to separate from dermis. We discussed how some seemingly innocuous drugs can hit the skin so badly, how to distinguish this disorder from toxic epidermal necrosis – it’s more sinister version- and shared our uncertainties on the role of steroids. I was about to move to the next bed, when I eyed the haggard face of the patient’s mother at her bedside. I decided to go back to the beginning.

“Tell me her story, in your own words,” I asked the old woman. “It started with a simple fever. She went to a local doctor in her village who examined her and found nothing wrong. He gave her an injection and a tablet to swallow. Within hours of swallowing the tablet, her skin began to burn and the body turned red”, the mother said. “We saw three more doctors in the nearby villages. None of them had an idea of what was happening to the skin. We hired an auto rickshaw and paid 500 rupees to reach this hospital”, her mother said.

My residents gave me more details on the patient. On admission, she had skin lesions that resembled a bull’s eye and few vesicles that dotted her face. The lesions soon spread and several macules, papules and bullae began to drape her body. Over the next few days, lesions erupted in crops. Her eyes were blood shot and mouth, sore. Her skin burned and she could not eat or drink. A week later, the bullae ruptured, leaving her skin denuded.

To restore her system, she needed to consume three thousand calories a day and required supportive care, preferably in a burn unit. She also needed intravenous fluids and electrolytes, steroids and antibiotics and needed to stay for several weeks in the hospital to get back her healthy skin.

I began to dig her past. Our patient grew up in a small village and was married off when she was only 16, the marriage abruptly stopping her education. Her husband, I learnt, was an unskilled labourer and the bread winner for the family. Her mother-in-law, struck by a stroke 6 years ago needed full support for all activities of daily living. And her little daughter, she said, “goes to a school in the village.”

Her mother stood nearby, holding her daughter’s weak hand as she sipped some water. Wrinkles of worries creased her face. Her son-in-law was running errands between the patient’s bed and the hospital drug store, buying her antibiotics, steroid injections, catheters, IV access devises and emollients. Although our teaching hospital offers subsidized care to the patients, they have to pay user charges and spend out- of- pocket on drugs and food. Every prescription that our residents wrote and handed over to him, made a hole in his pocket. Left with no money he had gone back to the village, confused and depressed. His wife needed to be in the hospital for at least two more weeks. There was no one to look after his old mother at home. He had no options but to take loans or sell his meagre assets if his wife was to earn her healthy skin again.

I learnt an important lesson. During our ward rounds, we question our patients, listen to our residents and elicit physical signs. We discuss, debate and critique diagnostic tests, treatment options, and prognostic indicators at the bedside. When challenged with a complex patient, we try to make an accurate diagnosis, using the best of art and science. The joy of making a rare diagnosis and solving a clinical puzzle often boosts our ego and fills our heart with an orgasmic pleasure. And as we pass by each bed, deciding on the likely diagnosis and the best treatment, we use esoteric phrases and pompous jargon to show our knowledge, to out-smart each other and take fierce pride in invoking statistics from the latest journal article. But how often do we detour into such non-academic issues as the social cost of an illness? How often do we pick up and address unvoiced concerns and worries that our patients, their families and friends carry? How often do we discuss the impact of illness on home economics?

Our medical students, interns, residents and young consultants need to know that hospitalisation can impact the family budget in a big way. And we need to learn that if we want our patients to leave the portals of hospitals in a happy frame of mind, we must delve into the depths of health economics in our bedside discussions.

Like beauty, Medicine is skin deep.