Act Like a Doctor, Think Like a Patient

Can Patient-Focused Medicine Be Taught?

This Never Happened Before!

I have never seen it rain like this–can you believe it?

People often don’t remember very well.  We’re always astonished by things that shouldn’t surprise us, because they happened many times before. We just forgot.

“Do you believe this rain?” your friend splutters. “In all my years, I have never seen it rain like this!”

Well, maybe he doesn’t think so. Chances are, if you look up the weather tables and show him that it has indeed rained like this before, and more, he won’t be impressed. Instead, he’ll harrumph and insist, “Yeah, but not like this!”

This sort of thing happens in medical offices too, all the time. Norman came in the other day.  He’s 92 now, bless his soul, taking care of an ailing wife. “My leg itches like crazy,” he said, pointing to his left ankle. “What on earth is it?”

“That’s eczema, Norman,” I said.

“I never had eczema,” said Norman, indignantly.

I looked at his chart. “Actually,” I said, “I treated you for eczema in 2006. And in 1997. In fact,” I went on, “I treated you for eczema when you first came to see me back in ’92. It was bad enough back then that we had to use oral medicine for a while, besides creams.”

“Oh,” said Norman. “I didn’t remember.”

Norman has plenty of company. When it comes to conditions that flare at intermittent and erratic intervals, many people have only vague and inaccurate recollections of past episodes. Lots of ailments work that way. In dermatology, we have eczema, psoriasis, acne, rosacea, hives, lichen planus (violet-colored, scaly spots), and alopecia (smooth bald patches), to name some of the common ones.

Although these diagnoses are all different, they have some characteristics in common:

  • They come and go, often returning years or decades later, with no pattern. 
  • Recurrences for the most part happen for no specific reason--and are therefore both unexplainable and unpreventable—all we can do is treat them.
  • These illnesses cause symptoms--itch, pain, embarrassing appearance, and so on.  But over and above any of these, every new recurrence disturbs and worries people because they find it so astonishing.

That’s exactly how patients themselves often put it. “This never happened before,” they exclaim.  “What the heck is going on?!”

When it comes to disease, doctors are taught to pay attention to pathophysiology: What caused the problem? How does it affect the body? Doctors are not taught to pay attention to the way patients experience illness, even minor illness: with shock, amazement, fear.

Acting like a doctor means making the right diagnosis and prescribing relevant treatment. Thinking like a patient means noticing that beyond symptom relief, people need their anxieties alleviated.

And if that anxiety comes from a firm conviction that “This never happened before,” a good way to address it is to point out that, actually, it has.

It’s rained hard before too. Don’t build an ark just yet.

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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