I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”
“No, it won't scar or leave a hole.”
“Will it leave a scar or a hole?”
“No. No scar or hole.”
“Will it leave a scar or a hole?”
“No scar. No hole.”
Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.
Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.
Anxiety is a great promoter of obsession.
“This spot is changing. Is it cancer?”
“No, it isn't cancer.”
“It's not cancer?”
“It's not cancer.”
“Are you sure it's not cancer?”
By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.
Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.
“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”
“No, Ma, just on this one.”
“Why not take off your other shoe, just to check.”
“There aren't any on the other foot. I looked.”
“We're at the doctor's. Let's take a look, to be sure.”
“Ma!”
Some day Samantha will get her chance to pay this forward.
Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.
Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”
Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.
“It's on my back somewhere.”
“Let's see. I'm looking at your whole back, and everything looks fine.”
“But wait, it's here somewhere. …”
If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:
“I'm looking at it. … I can see it. … And it's okay.”
Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)
Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.
Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.
When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.
Ah, blessed relief.
Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.
That's what I think, anyhow.
So what do you think?
So what do you think?
So what do you think?