It took Jared till the end of his third month on isotretinoin to tell me he was two-timing me with another skin doctor.
“She calls herself a cosmetic dermatologist,” he said, naming a nearby practitioner I didn’t know. “She formulates special skin care products tailored to my particular skin. The one she came up with for me is based on shea butter, and it feels great.”
I am always amazed at people’s capacity to believe that there is a unique regimen just right for them, preferably one specially formulated by an expert who is privy to a secret no one else knows. Shea butter, it turns out, comes from the African shea tree (Ugandan trees are best). Africans eat the shea nuts; Westerners smear on ground-up nut contents.
Nut of shea. Tree of tea. Eye of newt. Toe of frog. The list goes on.
But I digress.
“My other dermatologist was very unhappy to hear that I’m taking isotretinoin,” Jared said.
That didn’t seem very nice of her. I hadn’t murmured about her moisturizer, had I?
“What did she object to?” I asked. “Did her patients have problems with it?”
“She just said the drug is very bad,” said Jared. “She doesn’t like it at all. I was a little taken aback. I wasn’t expecting her to object so strongly.”
“But you’re still OK with taking isotretinoin?” I asked.
“Oh, yes,” said Jared. “It seems to be working, and I trust you.”
That was good to hear. I wondered whether Jared’s trust was based on the rigor of my scientific background or on my kindly smile and reassuring beard.
“Thank you, Jared,” I said. “I like isotretinoin a lot. It’s not for everybody, but for the last 35 years, I’ve seen it do excellent things for the appearance and self-image of many people.”
When I teach medical students, I often emphasize, as a point of professional etiquette, the impropriety of snorting or rolling your eyes at what patients report that other colleagues said and did. First of all, patient accounts may be imprecise or colored by their wish to build you up and flatter themselves for picking you. Second, just imagine what they might say about you at the next office they visit.
Reputation aside (you can hire folks to buff yours, if you like), my little exchange with Jared points up a basic difference between the way doctors think and the way our patients do.
What’s behind doctors’ professional lives is our assumption that diseases exist outside the bodies that the diseases inhabit. We therefore can offer a “treatment of choice” (or maybe a couple of them) that is best for treating a disease, regardless of who has it. This assumption is so obvious that we rarely think about it.
Obvious to us, that is, but not to our patients, to whom every patient has (to a large if not exclusive extent) his or her own disease. If possible, every patient wants a treatment tailored to each person’s unique makeup and predicament.
Jared is far from alone in playing both ends at the same time. From me he gets universal, evidence-based truths. From his other (more jealous!) medical mistress, he gets a skin care regimen tailored lovingly just for him.
The reductio ad absurdum of this treatment-just-for-you approach is our current societywide lust for precision medicine. Test your unique genes, get the treatment tailored just for you. Some rigorous scientists are trying not to so much debunk this effort as to point out how its promise is massively overhyped and unlikely to be worthy of the massive research investment it attracts. Perhaps their rigorous rationality will bear fruit, but they’re up against not just vested medical/industrial/venture capital interests, but the expectations of sick people who have always known that there is – that there simply has to be – a treatment out there that’s just for them.
Meantime, my next project is a skin care line I will call Eye of Newt.
Mock if you must, but tell me this: If people can prosper marketing a moisturizer called Kiss My Face or rake in the bucks with a skin care line named Urban Decay, then what’s your problem with Eye of Newt? You want focus groups?
Crowdfunding, anyone?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com .
