A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
One of the hardest points to get across to students is that much of the effectiveness of medical treatment lies in the mind of the patient, not just in or on his or her body.
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
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 new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com .
