"You’re magic," she said. "As soon as I made the appointment, my rash went away!"
I smiled noncommittally. I didn't want to break the spell.
"I got this rash on my bottom," she explained. "I showed it to my primary care physician and he said, 'That looks bad! You’d better see a surgeon.' "
"So I went to the surgeon and showed him the rash. 'That looks bad!' he said, 'but it sure doesn't need surgery. That's a fungus infection.' So he gave me a cream.” She held out a tube of nystatin.
"I used it for 2 weeks but it didn't help," she went on, "so I went back to the surgeon. 'That's a really bad infection,' he said. 'Use more of the cream.' "
"I kept using the cream but the rash still didn't get better. Then my husband said, 'Didn't that Rockoff fellow prescribe a cream for you a couple of years ago?' "
She showed me a tube of desonide. "You said I could use it on my face and my bottom," she said, "and it cleared me right up. Isn’t that amazing?"
I agreed that it was and had a look. The rash was gone.
Concerning her case, I had little to discuss clinically with my student. He already knew that not every groin rash is fungal, but he also knew that in the greater world the default diagnosis is that every rash is probably a fungus, even if the cream often prescribed is anti-yeast. What interested me was this patient's attitude toward her experience, marked by gratitude, even wonder, rather than the irritation and resentment she might have expressed.
She could have said: “How come my primary doctor didn't know what this was and thought I needed surgery? Why did the surgeon think it was a fungus, and when I said the fungus cream wasn't working, why did he tell me to use even more of it? Why did it take my husband to get it right?"
But she did not say any of these things, she didn't even think them. Even when she referred to the time and "hundreds of dollars" the doctor's visits and creams took, there was nothing in her tone to suggest she was biting her tongue. She was just delighted that everything had worked out.
We often complain that patients don't cut us enough slack. If things didn't work out as well as they wished, as fast as they expected, or if we kept them waiting longer than they wanted – whether or not any of this was within our control – they let us know loud and clear that we haven't measured up.
Letting off steam from time to time about patients and frustrations is fair enough, but it’s worth reflecting on how many patients cut us plenty of slack, perhaps more than they should. I’m sometimes bemused, for instance, when I see a new acne patient who has just moved to the area. I ask him what he's been treated with.
"Minocycline."
"How long?"
"Three years."
"Is it working?"
"No."
"So what did the doctor say when you came back to see him?"
"Keep taking the minocycline."
Considering the people who call us every 3 days to complain that their pimples aren't going away, how do we explain why this gentleman (or his mother) didn't ask, "Say, doc, haven't you got anything else?"
Challenging an authority figure is not easy for most people. Many are reluctant to do so, if for no other reason than if they don't trust the person they're asking advice from, where exactly does that leave them?
And so many patients have so much trust and confidence in us that they overlook – or don't notice – if we fail to get the diagnosis right the first (or second) time, if the medication we prescribed had a side effect we didn't tell them about, or if it cost them a bundle because their insurance covered less than we figured.
The truth is that most patients cut us plenty of slack. Sometimes more than we deserve