Act Like a Doctor, Think Like a Patient

Can Patient-Focused Medicine Be Taught?

STD's Without Sex

The Immaculate Infection?

If your doctor said you had a sexually-transmitted disease, but you weren’t having any sex, how would that make you feel?

This happens often. Consider molluscum contagiosum.

Molluscum is a common and homely condition that produces clear little bumps with a tiny navel in the center of each. Everybody knows that molluscum is contagious, often sexually, because:

1. All the textbooks and websites say so

2. It’s called “contagiosum,” isn’t it?

If you look molluscum up on the web, you will learn things like, “skin-to-skin contact spreads it easily,” and “it doesn’t always come from sex, but that is how most adults contract it.”

But maybe not so much.

As a clinician, I see several cases of molluscum every week, many in children. Although I always ask about whether family members or sexual contacts have little bumps too, the answer is “no” 95% of the time. And mollusca are hard to miss (see the photo)—there are often dozens of them, and if untreated they hang around for 12-18 months before going away spontaneously. (Which they always do, so I leave little kids alone instead of torturing them by applying painful acids or freezing with liquid nitrogen.)

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By now I’ve seen mollusca most anywhere on the body you can think of. Kids often get them on the chest and under the arms. Young adults tend to get them in the groin.

So in adults they must be from sex, musn’t they?

But if so, I ask myself, why do so many of my molluscum patients either have partners who don’t have them (and again, they appear on the outside of the skin, not internally, so really you can’t miss them), or else they have no partners at all.

So what kind of sex are they getting it from? If it’s not physical sex, then what? Metaphysical sex? (People who’ve tried both say there’s no comparison…..)

Doctors are trained to ask what causes diseases and how to treat them. We are not trained to ask what sense patients make of our advice and recommendations.

If you’re the mother of child with mollusca all over his chest, and the doctor says it’s very catchy, what do you do? You keep him out of the tub with his brother, and you don’t let him in the pool all summer. You do this even if your kid has been bathing and roughhousing with his siblings for weeks or months and nobody else got it. Your doctor told you, didn’t she?

And if you have mollusca on your penis but your partner doesn’t have any, imagine what you do when your doctor says you most likely have an STD. Or guess what you think when he tells you it’s probably from sex and you haven’t had any in 3 years?

These are not fanciful scenarios. I encounter them all the time.

Acting like a doctor means knowing the cause (for molluscum, a poxvirus different from the HPV that causes ordinary warts, or genital ones), and the likely clinical course (spontaneous resolution after a long period), as well as which treatments are available (freezing, applying blistering agents, and so forth.) It also means inquiring about family members and sex partners who might have them, so if it’s appropriate they can be treated or evaluated for other STD’s.

Thinking like a patient means also asking yourself:

1. Does what I know and what I’ve been taught make sense for this particular patient?

2. What will the patient make of what I say? Will my advice make him better off, or instead mosty anxious and confused?

Medical knowledge underlies all doctoring. It should be applied in the service of the patient. Understanding how to do that means thinking like that patient.

 

Dr. Alan Rockoff has practiced Dermatology since 1979. He is Clinical Assistant Professor of Dermatology at the Tufts University School of Medicine.

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