Act Like a Doctor, Think Like a Patient

Can Patient-Focused Medicine Be Taught?

Toenails As Big As Potatoes

Am I turning into Grandpa yet?

Just looking at him, you wouldn’t take Stanley for the type who cared what his toenails look like. But you would be wrong.

Stanley actually came by about something else–new spots on his face--so his toenails were almost an afterthought. But once I told him he didn't have skin cancer, he pointed to his left foot and asked, “How come the big toenail and the fourth one have little pits in them?”

I’m used to nail questions like this, especially from women. Their usual concern is that funny-looking nails are fungal and therefore contagious or gross or both. Sometimes these nails really are fungal, but the ones that aren’t can be hard to treat because they’re just mechanical issues-- toenails banging against tight shoes, for instance, or long fingernails that get pulled away from the nail bed and leave a dead-white air pocket beneath. I often encourage women with such problems to hide their nails with polish. Many have heard that doing that might “seal the infection in” and are therefore reluctant to hide changes that other people see and misinterpret. This leaves them embarrassed and self-conscious. Best to hide them from prying eyes.

But I certainly wasn’t going to recommend nail polish to Stanley. Mauve is just not his color. So I just told him that it wasn’t fungal and that it was okay to ignore it.

Then, as he put his shoes on, he told me what was really on his mind. “My grandpa had fungus in his feet when he got older,” he said. “By the time he passed away, his toenails were as big as potatoes.”

To doctors, diagnosis is a static thing: something you have. To patients, however, diagnoses are a dynamic process: something that wasn’t happening before but is happening now. They are part of a story. Patients want to know not just what the diagnosis is but what it means, and an important part of that is where it’s going. They want to know where how the story is going to end.

You might think that concerns like those would only apply to serious illnesses like multiple sclerosis or cancer. If you listen to what they say, however, you’ll realize that people ask the same questions about trivial matters like a mole on the face (“Will it get bigger?”), a few eczema bumps on the finger (“Will it spread all over my body?”).

Or pits in two toenails. The problem is not what the nails look like. That would be “vanity.” The problem what the toenails are going to look like. Life is not a snapshot; it’s a story. Where is this one going? (“Am I turning into Grandpa—already?!”)

Acting like a doctor means making the right diagnosis and treating it if you can. Thinking like a patient means getting a handle on what the diagnosis–or the suspected diagnosis–means to the patient and how it folds into the story of his life.

“Your grandfather obviously had an extensive toenail fungus infection if his toenails look like potatoes,” I told Stanley. The pits on your toes aren’t fungal, so they aren’t going anywhere. No worries.

Stanley smiled, put on his shoes, and left. He wasn’t infected and catchy. And he wasn’t turning into Grandpa. Not yet, anyway.

 

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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