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“Rub the cream in until you can’t see it,” I tell her, “and then”—here I pause—“it can’t come off.”
Her eyes may widen in surprise. Or she may come right out and say, “I didn’t know that!”
It took me 15 years to figure out what was going on. Patients would come back for follow-up and apologize. “Sorry I couldn’t put the cream on at night, Doc. It would just come off on the bedclothes.”
“Was it greasy?”
“No, not greasy,” they’d say. “It would just come off.”
This didn’t seem to make any sense, until a light bulb clicked on. “Wait,” I asked a patient one day. “You’re concerned that the cream would rub off on the bedclothes and wouldn’t work, so you didn’t put it on at all.”
“That’s right!” he said.
I confirmed this with several other patients. Many people are sure that if you put on a cream and then let your clothes touch the skin you put it on, or if you wash that part of the body later on, that’s like taking a pill and spitting it out. Waste of time.
Ever since, I use this formula when I prescribe a cream: Put it on, rub it in, and then it’s where it needs to be and won’t come off.
A fair number of patients look surprised. “Really?” they say. “You mean I can get dressed and let my shirt or pants touch where the cream is? I can put the cream on my face and put lotion or makeup right over it? It won’t dilute the medication and make it not work?”
I assure them it won’t. Now they will actually use the prescription.
That people think and act this way may seem hard to believe. But it you prescribe creams a few dozen times a day for 35 years, you pick up a few things.
Medical school does not teach this. There you learn what causes disease, which treatments help, how they act and what side-effects they have. Students memorize long and complicated tables of cortisone creams. These rank the creams’ effectiveness based on how well they constrict blood vessels in rabbit ears.
Students do not learn how to pay attention to what ideas in patients’ heads might make them not use the creams in the first place.
Patients have many reasons for not using medicine as prescribed. They may forget. They may be fearful about what they’ve read or heard. (“Don’t cortisone creams thin the skin?” “Can’t antibiotic acne gels cause colitis?”)
Or they may just decide that the cream will rub right off and be useless.
Acting like a doctor means figuring out what is wrong and prescribing what can help. Thinking like a patient means understanding how she understands what you’re asking her to do, and how her opinions might get in the way of her doing it.
If I made clothes, chances are that I would not tell a customer, “Hey, the jeans I make are great. If you think they don’t look good or fit well, then you’re just wrong and I can’t help you.”
As a doctor who prescribes treatment to make people better, shouldn’t I be at least as interested in knowing what blocks them from using it as I would be if I manufactured jeans?
