It was the best of psoriasis. It was the worst of psoriasis.

OK, maybe it was neither the best nor the worst, but Thursday two weeks ago brought in a whole lot of psoriasis.

Vito is 60ish, a shlumpy gent who drops by every 6 months and asks me to inject cortisone into the small patches he gets on his elbows, wrists, and knees. Creams make them flatter, but he wants the spots gone. If I miss a small one, he points it out and makes sure I shoot it.

Frank is 40. His main problem is a pink fungal rash on his shoulders and upper chest. That really bothers him. What about those red circles lower down on his back? “Oh, that’s just my psoriasis,” he says. “I don’t care about it.”

Boutros is the youngest, about 30. He’s very worried about these spots that cropped up on his legs. His doctor in Lebanon told him they’re psoriasis, but the cream isn’t working, and why are they spreading all over the place? Is it in the blood? Is it some kind of infection?

If you look psoriasis up in a textbook or on a website, you’ll read that it’s thought to involve the immune system, that it may have a genetic component and can be aggravated by stress. You’ll also see that various treatments can be effective: creams containing steroids or vitamin D, sun or ultraviolet light, drugs by mouth or by injection that affect immunity.

All these are true facts—from the doctor’s point of view. They just don’t consider what patients think. Does that matter? Sure it does. What’s the good of facts that don’t tell the patient what he wants to know, don’t answer the questions he wants to ask, don’t give him what he considers results?

Vito doesn’t care about the causes of psoriasis. He just thinks it’s ugly. (He doesn’t look the part of someone who’d care about that sort of thing, does he? But there he is.) Creams smooth the spots, but if they’re not gone they’re still ugly. That’s not what Vito calls “working.” So it’s twice-yearly steroid shots for him.

For Boutros, appearance is secondary. He just wants to know what the hell is going on. Talking about immunity, stress, or genetics doesn’t doesn’t tell him what he wants to know: Why is this happening to me, on my legs, now? If it’s immunity, why is his immune system screwed up all of a sudden? Stress? He’s always stressed, especially when he gets weird rashes. Genetics? Did he just grow new parents or something?

As for Frank, he cares about neither about causes nor treatments. Three years ago, by the way, he did ask for psoriasis treatment. Since then, like many patients with chronic conditions, he got bored and gave up. If you ask me why he cares about the pink patches on his shoulders but not about the red spots on his mid-back, I couldn’t tell you. Many patients draw distinctions between what bothers them and what doesn’t that make little sense to anybody but them. Frank doesn’t care about his psoriasis right now. A doctor might think that the “treatment of choice” for the psoriasis he has is to put steroid creams under Saran Wrap overnight. Frank would consider that way too much work. His treatment of choice is the choice to not treat.

Acting like a doctor means making the right diagnosis and knowing what you can do about it. Thinking like a patient means tailoring this knowledge to what the actual patient thinks and wants to know and is prepared to do.

Vito wants his spots gone, because he hates to look at them. (Question: How is Vito different from a middle-aged woman who wants me to burn off every single tiny white facial cyst, and every time I skip one says, “You missed that.”)

Boutros doesn’t want lectures on genetics or physiology. He doesn’t like his spots, of course, but what really worries him is that there’s something wrong in his blood that’s coming out onto the skin, or that he has some catchy fungus crawling all over him. I can’t make the spots disappear, and I certainly can’t stop new ones from coming. What I can do is figure out what he’s actually afraid of, so I can talk him out of it. In the meantime, we can flatten his spots as best we can.

As for Frank, he doesn’t care, which is fine with me. Quite often, the best I can do for people is to strip their symptoms of significance so they can ignore them. There are better things to do with your day than worry about your body.

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