My easy-to-remember "isms" aid patient communication

I never seem to have enough time, especially when I am seeing patients. And the older I get, the faster time flies. But age and experience have also come with increased clinical efficiency.  Making medical decisions became faster and easier way before I was able to condense the time it takes to explain why. So, additional years of repeating justifications to students, residents and patients have honed explanations into my -isms. These are kernels of truth packed into few easy-to-remember words, as an efficient way to communicate.

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Most experienced clinicians have their own -isms, and my collection includes those from my own mentors and esteemed colleagues. I thought I had enough self-awareness to know most of my own, but I also reached out to friends (including present and former residents, my nurses and PA) and family in a 360 degree feedback on any that immediately came to mind, as well as additional -isms learned from someone else, or their own -isms. I am proud to say that a few replies from current residents gave credit to junior colleagues that I believe learned the -ism from me. By the same token, I realize that I may be inadvertently taking credit for an -ism that I learned elsewhere. In some cases, Google helped verify an origin. If your recognize one of yours, I welcome feedback.

Preventive care "isms" 

The "isms" I use most often are about common conditions that are either best managed with preventive care or difficult to treat. But convincing some patients (and their parents) to adhere to preventative treatment or opt against aggressive procedures requires a good explanation. Below are several that have served me well.

• The peds "ism" for counselling parents is "anticipatory guidance." This often includes monitoring, rather than intervening. With regards to hemangiomas, Dr. Milton Waner countered the obsolete “benign neglect” approach with, “There is nothing benign about neglect.” Dr. Ilona Frieden coined a related -ism, “active non-intervention” as a more supportive approach to hemangiomas, also applicable to many other conditions that may benefit from close monitoring.

• “There's no glory in prevention.” Providing anticipatory guidance does not often receive the same degree of credit as quick-fix interventions like a surgical procedure, because the benefits are difficult to prove. But prevention is often the best treatment. I use this phrase to encourage use of emollients and bleach baths for children with eczema, for advising children in wart-prone families to wear water shoes at public pools and to convince parents of infants with high-risk distribution hemangioma precursors to start propranolol.  

Childhood skin disease has unique challenges

Parent management-isms

I have a few mottos for parents who are unnecessarily concerned about a skin lesion, and insist on blood tests or a painful procedure for their non-assenting child. 

• “Radiologists know that spots are common on bones and internal organs. People worry more about spots on the skin just because they can see them.” Some are “ditzels” of no consequence, while others are “iceberg tips”. I let parents know that the visual prominence of the lesion is not necessarily proportional to its risk, and that “It’s my job to know when to worry.”

• Dr. Sarah Jensen (who completed her residency in my department more than a decade ago) tells patients "There are a multitude of treatments for warts, because none of them are very successful."  My take on that -ism is “Warts are common. If there was a uniformly effective treatment, your doctor would have offered it. And if I could guarantee that one treatment would work, no matter how difficult or uncomfortable, or if treating now would prevent a bad outcome, I would hold your child down, even kicking and screaming, to get it done.”

• Only after seeing thousands of patients with skin disease of similar and widely varying impact has it become obvious that, “What you have and the way your feel about it” are unrelated. It is important to acknowledge a patient’s and parents’ perceptions, but to help guide them to a rational decision about the risk:benefit ratio of evaluation and treatment options. So, “Never make the evaluation or treatment worse than the disease” is a valuable sequel.

• Several trainees reminded me about teaching them to: “Treat the patient, not the parent.”

• Many remembered my molluscum BOTE (Beginning of the End) sign (http://www.ncbi.nlm.nih.gov/pubmed/23545377). This reflects the power of catchy phrase and Googlable publication.

Eczema-isms

Eczema-isms

Patients with eczema fill 50% of my clinic schedule, but take 80% of my time. So I have had a lot of practice in honing eczema-isms.

• “Eczema doesn't kill you, but it can ruin your life” applies to families and patients with severe eczema. I hope it communicates that I feel their pain, including the lack of a well-defined safe and effective treatment.

• The cosmeceutical-industrial complex reflects the strongest incentive to produce topical products for people with sensitive skin: marketability.  This allows me to equate appeal based on packaging, odor, tactile quality and “natural” ingredients (rather than safety or health-related benefits) with that of other products like candy and cigarettes. More than one resident mentioned my related “poison ivy is natural.”  My newly board-certified colleague, Dr. Stephanie Frisch translated this -ism into "What you don't use is more important than what you do use."  

• For patients with eczema, identifying and avoiding contact allergens is an important aspect of initial management. While patterned involvement can suggest likely topical allergens, I refer to erythroderma as “being on fire”.  Dr. Tinatin Gotsiridze reminded me of waiting until  “the smoke clears” to see a suggestive pattern.

• I often see frustrated patients with severe eczema who have been treated for years with cycles of prednisone and antibiotics. This approach gives them quick relief followed by rebound flares. I call this the “roller coaster” when explaining my approach to “get off the roller coaster” and achieve more enduring remission.

• Other -isms are related to the important issue of using an appropriate quantity of medication. These include:  “If you use too much it’s bad for you; if you use too little, it won’t work”. For parents hesitant to use topical corticosteroids or calcineurin inhibitors, I remind them that too much water, sun or even food can kill you. (I have to give credit to Parcelsus for his 500 year old -ism, “All things are poisons, for there is nothing without poisonous qualities. It is only the dose which makes a thing poison.”)  Dr. Stephanie Frisch, modified this -ism to "It's not what you use it’s how much", and reminded me that underuse of topicals is also applicable to acne. Dr. Pearl Kwon shifts responsibility to the patient by saying “The M.D. after my name does stands for medical doctor, not magic doctor.”

Miscellaneous-isms

Miscellaneous-isms

Below are a few miscellaneous -isms.

• With regards to making difficult decisions about recommending higher-risk treatment for conditions with a spectrum of severity, such as systemic therapy for eczema or intervention for disfiguring birthmarks, I equate it to pornography: you know it when you see it.

• Lesions that are not disfiguring can be considered “distinguishing” in the same category as hair color, eye color, and even piercings or tattoos.

• Dr. Alanna Bree reassures patients with concerns about distinguishing features with: “Your beauty comes from the inside, not the outside.”

• I often try to put painful procedures into perspective for needle-phobic children, by telling them that the procedure requires a little “pinch”. If this elicits fright, I ask them “What do you think hurts most?” Then I tell them the answer: “feeling scared”. That aphorism is too brief for some children, so I distract them with a true story about the patient that taught it to me. He was a husky 8-year-old boy who came to my clinic from the emergency room in a wheelchair because he had joint pain that made it difficult to walk. His legs were covered in giant bullae. At that time, I used the word “shot”, as an acid-test to help evaluate a child’s degree of anxiety. When he heard that word, he leaped off the table and ran for the door. Ultimately, the biopsy required four people to hold him down. After I injected the lidocaine, and said, “There, it’s done.”  He replied, “Was that all? Why didn’t you tell me?”  Dr. Courtney Tobin says it a little simpler, “The anticipation is worse than the procedure.”

• My daughter even offered a few of my doctor Mom-isms that she sometimes uses when giving her college roommates second-tier skin advice:  "Put petroleum jelly on it.” And, "Don't worry unless it gets worse, doesn’t go away or changes."

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I also appreciate others’ -isms

I also appreciate others’ "isms"

• Dr. Anne Lucky’s explanation for a halo nevus is "You are an angel and it's your own little halo."

• A few years ago, Dr. Ilona Frieden solicited -isms from the membership of the Society for Pediatric Dermatology and presented the submissions at a meeting. My favorite was “The Internet is like a flea market. You have to be able to distinguish the trash from the treasure.”

• After creating brilliantly efficient designs for many documentation templates, the EMR product specialist in my department says: “You wouldn't believe how hard it is to make something easy.” In a different era, Mark Twain’s -ism for the same issue was, “I would have written a shorter letter but I didn't have enough time.”

• Dr. George Nahass was credited with "Let the process declare itself" for an early-onset, non-specific eruption that can be closely monitored rather than subjected to costly, invasive tests. 

• Dr. Mark Hurt was credited with "There is nothing wrong with saying ‘I don't know’."

• Dr. Scott Norton (via Professor Saul Lieberman, the great Talmud scholar) taught me that “Nonsense is nonsense, but the history of nonsense is scholarship.”

• Sometimes I am disappointed by what seems to be lack of interest and responsibility towards difficult patients. As one orthopedics resident put it, “There are two types of problems: my problem and not my problem.” Dr. Jean Bolognia refers to these patients as “hot potato” or “bad penny”, in an effort to inspire trainees to recognize and embrace the challenge of helping them.

• Judge Judy says, “How do you know when a teenager is lying? They are moving their mouth.”

• Dr. Howard Koh, dermatologist and the former Assistant Secretary for Health in the Department of Health and Human Services, says “Blessed are the flexible, for they will not get bent out of shape.”

• Favorite -isms from the famous include Frank Lloyd Wright’s “There is nothing so uncommon as common sense.” And Einstein’s “If a cluttered desk signs a cluttered mind, of what, then, is an empty desk a sign?”

• But memorable -isms also come from those who enjoy anonymity: Mary Hoff, the wonderful woman who braves our front desk says “It's easier to be busy than to look busy.” And two whose authors I could not locate: “Try not to let your mind wander, it's much too small to be outside by itself.”  And, “What if the hokey-pokey really is what it's all about?”