You will forgive me for pointing out that Aleela is very beautiful. Her luminous eyes and delicate features compel admiration.
Which makes the fact that her eyelids are thick and swollen and her upper lip is dark and scaly all the more jarring.
There’s no mystery about what she has: atopic dermatitis, or eczema. That much you can see from across the room. The question is why she isn’t treating this more effectively, since treating eczema is so easy to do, and doing it would erase her facial imperfections. Many women and men go to a lot of effort to camouflage facial imperfections a lot less noticeable than hers.
It turns out that Aleela is not treating her skin problems at all. In fact, she has some large, dark, scaly patches on her chest and back and arms. She isn’t treating those either. “A doctor gave me a cortisone cream once,” she says, “but it didn’t work.”
When it comes to evaluating what patients mean when they say things like the that, you have to ask, “What does she mean by, 'It didn’t work?'"
Although eczema comes and goes, at least from time to time, its visible changes are pretty easy to get rid of. Why then does Aleela say that the treatment she got did not help? Did her rash never go away at all, even when she used it? Did it go away but come back? Maybe the cream actually did work, only she stopped using it because she was afraid it was too strong or not good for her.
Because trying to figure out the answers to questions like these can be hard, I usually treat someone in Aleela’s circumstance her by prescribing a medium-strength cortisone cream—one that can’t thin or damage the skin—so the patient and I both can both see if it brings quick and dramatic and improvement. This usually takes just a few days. If that happens, it’s easy to convince the patient that she doesn’t have to just live with her eczema after all.
Aleela was happy to go along with a trial like that. “Great,” I said, and then added, “By the way, your scaling and thickening will get better fast, but even your dark discoloration will go away too, more slowly, because eczema just affects the top layer of the skin and doesn’t cause permanent damage or scarring.”
That got her attention. Aleela’s eyes widened in surprise. “You mean I didn’t damage the skin by scratching it?” she asked.
“Absolutely not,” I said. “No permanent damage.”
“I can hardly believe that,” Aleela said.
Although the word “damage” does not come up in medical discussions of skin problems, patients use it all the time. Not only do they often think that coarsened skin texture means permanent, irreversible skin damage, but--even worse--they think that they themselves caused the damage by scratching. (And because eczema itches like mad, who could blame them?)
Now that Aleela no longer has to think that she is damaged goods--or that she messed herself up irreversibly--she can actually treat her condition, eliminate the itching and the scaling, lighten her dark pigmentation--and show the world the smooth, even, luminous countenance that the good Lord gave her.
Medically, that’s easy, but medical treatment is not enough. It’s necessary to speak to her in her own language, to know what she means by “it doesn’t work” and by “I think my skin is damaged.”
Doctors are not taught, however, to think and speak like patients. It’s not part of the professional deal.
More’s the pity.
Dr. Rockoff’s new book, Act Like a Doctor, Think Like a Patient: Teaching Patient-Focused Medicine, has just been published by Medical Education Press. The book focuses on the need for medical providers to know not just how to diagnose and treat disease, but to understand patient and make them feel better. You can order the book on Amazon.