Stu came in for a skin check. Except for freckles on his shoulders and back that were left over from sunburns he got as a careless kid, he had no worrisome spots. But he did have a big, ropy scar on his left shoulder, complete with “railroad track” stitch marks stretching across it. Not a very elegant surgical job.
“What did you have removed there?” I asked him.
“Just a cyst,” he said. “Nothing serious. I didn’t like the way it looked, so I had it cut off.”
“I guess the scar didn’t turn out the way you hoped,” I said.
“Not really,” said Stu. “But it’s not the biggest deal in the world. In general, I’m a good patient. I follow instructions, and treatments tend to work for me.”
I told him I wished more people shared his attitude toward things. At the same time, I thought about his self-description: “I’m a good patient.”
You’ll seldom if ever hear a doctor refer to a patient as “good” or “bad,” but you might hear patients quite often call themselves “a good patient” or “a bad patient.” What do they mean?
Most of the time, patients who use this phrase refer to their level of cooperation with medical care. For them, “I’m a good patient” means:
What these boil down to is a patient who thinks of himself as cooperative and considerate, someone easy to get along with. The opposite of a good patient of course is a bad patient, the doctor’s office equivalent of the sort of difficult person who either doesn’t mind giving other people a hard time, or actually seems to enjoy it.
But if you listen to him carefully, Stu is telling us that there is more to “a good patient,” than being nice. There is in fact one more criterion for admission to this category, which is:
What makes a person good, in other words, is that he or she does not let the doctor down by failing to improve.
Medically speaking, that doesn’t make much sense. If a doctor’s treatment doesn’t work, you would think that should count against the doctor, not against the patient. Objectively that may be true, but it isn’t the way many patients think about it themselves. Instead, they react to a doctor’s opinion that their problem—perhaps acne or eczema—is not doing well not the way they would to a sober evaluation of what is going on with them medically. Instead, they take it as an expression of the doctor’s disappointment, even a kind of insult. They look and act the way you did when your teacher handed you a test with a look of sorrowful disappointment that said, “Look, you let me down.”
I don’t encourage patients to feel this way. I just notice when they do.
Just as people think of the themselves as having a special, even unique personality, something anybody who knows them would recognize, many also think they have a unique health personality. They will then say things like:
"I am a healthy person. I don't get sick."
“Strange things happen to me that don’t happen to anybody else.”
“I am a sensitive person. I get weird reactions to things.”
“My body does not like pills. Any pills.”
Doctors hear statements like these all the time, even if they may not pay attention to them. What patients are referring to is their assessment of the way their body—as opposed to somebody else’s body—reacts to things, whether those things are allergens or medical treatments.
That’s what Stu was saying. As far as he is concerned, his body gets better with treatments. Which treatments? Any treatments. So since he’s the kind of person who gets better with treatments, he assumed that when the doctor took off his cyst, he would heal well because basically that’s the kind of person he is.
In this sense, saying “I’m a good patient” is like saying, “I’m lucky.” If your friend tells you he’s lucky, you pretty much know what he means, but you don’t ask him to prove it. After all, his opinion about himself doesn’t have much to do with you. If he thinks he’s lucky, he may buy a lottery ticket, but that’s his affair.
If you’re not his friend, however, but his doctor, his opinion of himself may have a lot to do with you. Many patients, after all, don’t follow instructions. Studies show that this behavior—not taking your medicine—is bad for health, hard to understand, and very tough to modify. Counseling, reminders, ad even high-tech pill-counting gadgets, don’t improve things much.
It might be a good idea if doctors learned how to think more like patients. That way they might be in a better position to figure out why some patients are more likely to cooperate, or not cooperate, with whatever treatment they recommend.
Which would be helpful for both doctors and patients, "good" ones and "bad" ones.
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 patients and make them feel better. You can order the book on Amazon: