Maximizing the physician-patient relationship

Dr. LevineA middle-aged woman presented to our office with a history of recurrent blisters on a localized area of the low back. She reported that her most recent episode was definitely caused by the bite of a spider which she found in her bed on the morning she developed the blisters. When I asked how this was consistent with her history of recurrences, she replied that perhaps previous spider bites had left some foreign material which activated the blistering process.

At the risk of incurring the wrath of those of you who are politically correct, this is a crazy story by any measure of such things. I understand that one of the tenets of modern medicine is to obtain a history by attentively listening to what the patient has to say and incorporating that information into one’s final diagnosis.

I have a different view; often the history is helpful, but sometimes it is not only not of value, but actually drives one away from the correct answer. In the case of the person with the blisters on her back, it is pretty clear that the diagnosis is recurrent herpes simplex virus infection and that pursuing her spider bite theory will not be at all fruitful.

There are many similar stories that we hear such as sun exposure causing a rash within seconds or minutes of exposure, foods that produce skin allergies only some of the time and rashes from laundry detergents and other innocuous products being responsible for myriad skin reactions. I know that this is a minority view, but in my estimation, most reports of contact dermatitis turn out to be completely spurious.

How do we manage patients with untenable tales to tell? This is actually somewhat of a philosophical question as much as a healthcare issue. My friend, the clinical psychologist, states that the main point of one’s existence is to arrive at the truth. If that is so, many office visits would end with disgruntled patients who feel that their physician either “didn’t listen to me” (one of the major complaints that patients express on physician rating sites) or who feel patronized or made to feel ignorant or unintelligent. On the other hand, if all goofy theories were left unchallenged and uncorrected, the very important educational aspects of an interaction between a physician and the patient would be severely compromised.

It is at this patient interface that the art of medicine becomes paramount. I have learned from painful experience that one must be able to accurately and quickly determine what a person is seeking and try to satisfy his desires without compromising his well-being. After 45 years of being a physician, I am still struggling to get it right; I still offend patients occasionally with a blunt assessment of their problem, and in the other direction, sometimes allow extensive medical workups to proceed based on a pretty weak history. In the case of the woman with recurrent herpes simplex virus infection, I probably should have allowed her to keep her notions of spider bites while treating her for the viral infection. By the end of the office encounter, she was very angry with me and actually called later to inform me that I did not know what I was talking about and that she was going to seek the services of a competent dermatologist to care for her future needs.

There are circumstances where the truth matters a lot, in spite of the patient’s protestations to the contrary. We have all seen individuals with delusions of parasitosis who have a persistent mistaken notion that they are infested with bugs or have other foreign material coming out of their eyes or their skin. The signs and symptoms of this disorder often ruin their lives. The easiest way to survive this office visit is to enter the delusion and treat for scabies or some other infestation. The patient will leave the office happy that at least someone is sympathetic to his plight and believes what he is saying. However, we all know that this will not solve the problem. Patients in this situation hate to hear that they may have a psychiatric illness and will almost always resist consulting with a mental health worker, so that is not a viable option.

There is another way to handle this situation which may lead to a remarkable improvement without compromising the truth. I deflect all conversation about parasites without an outright refutation of their views and emphasize that that problem is neurologic in nature and requires systemic therapy to improve the condition. I acknowledge to them that they must suspend disbelief of their strongly held views about their malady for only one month while the treatment (pimozide) cures the problem. Only about 50% of patients with this disorder go along with this explanation, but I feel very satisfied when those who accept the treatment return in a month with remarkable improvement.

There are times when it may be in the patient’s best interest for us to suspend disbelief ourselves. A teenaged boy being treated with isotretinoin was arrested for possession of marijuana and for shoplifting. His grandmother who accompanied him to the office visit indicated that her grandson is a really good kid who has never been in trouble with the law before. He was soon to go before a juvenile court judge who will decide whether this boy will be punished. The question is whether his isotretinoin therapy has caused his mental state to change such that he has behaved in an anti-social way.

After hearing this story, I rather doubted that the drug had anything to do with his behavior. However, in trying to do what is best for this boy and not knowing with certainty what caused his social problems, I discontinued his use of isotretinoin immediately and suggested that he bring a copy of his clinic note with him to the judicial hearing, which stated that he may have emotional instability related to the use of isotretinoin. Perhaps I am allowing an unlikely story to go unchallenged, but it may be therapeutic in this particular case.

Nobody has ever told us that being a capable physician is easy. A large part of the difficulty centers on the patient-doctor interaction and how one maximizes the benefits that the patient accrues by the care he receives. It is our responsibility to develop the skills that allow us to discern fact from fiction and then somehow use our judgment to develop a management plan that is best for that person.