Joan showed me the muddy pigmentation on the side of her neck.
“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.
“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”
Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.
Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.
“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.
I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.
Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”
I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.
Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?
Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.
My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.
Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)
Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.