Commentary

Nipping buds, kicking butts, being safer than sorry


 

References

Brad came in with his mother for me to treat a small wart on the sole of his left foot. “It doesn’t bother me,” he said.

“I had one of those when I was Brad’s age,” said his mother, Mary Lou. “We neglected it and it really grew! With a thing like that, you have to nip it in the bud.”

We all learn little maxims about how the world works and what to do about it. One of these is that to avoid trouble, you should nip things in the bud.

Dr. Alan Rockoff

Dr. Alan Rockoff

This sounds like it makes sense. Sometimes it’s actually true. But there are other times when what you’re trying to nip doesn’t have a bud.

If you have a plantar wart on the bottom of your foot and you don’t treat it, here are some things that can happen:

•  It can grow and become painful.

•  It can stay the same for years, never bother you, and go away.

•  New ones can appear elsewhere on the sole.

•  It can disappear tomorrow afternoon.

Which will happen? For the individual case, I have no idea. Like you, I’ve seen ‘em all.

There are reasons other than functional disability to treat plantar warts. For instance, they’re ugly and embarrassing. So if treatment is not too painful or expensive, why not? But sometimes we freeze it – a standard treatment – and it takes forever, visit after visit, and the wart is still there, grinning complacently. Some insurance plans don’t cover treatments unless the wart hurts, so therapy gets too expensive.

That’s when it might make sense to explain to the patient that you can nip some buds off plants to help them grow better, but you really can’t nip the buds off warts, which have neither roots nor buds.

Another maxim we all pick up is that it’s better to be safe than sorry. That sounds like plain common sense. “Can’t you take off that mole?” asks Annie. “I’m sure it’s bigger that it used to be.”

It’s just an ordinary mole, though, and it doesn’t look worrisome. All moles grow – they start out small and get a bit bigger before they stop. Plus, Annie is a young woman, and her mole is on her face. Even if a plastic surgeon takes it off, she’ll have a scar with no wrinkles to hide it in.

I explain this to Annie. “But isn’t it better to be safe than sorry?” she asks.

Well, sometimes maybe. Just not this time.

Ankur has eczema. He is really frustrated. “Doctors keep giving me creams,” he says. “The rash gets a little better,” but then it comes back. “I’d like you to give me a treatment that will kick it in the butt.”

What Ankur wants, of course, is for me to do something that will shove eczema out the door and then lock the door behind it so it can’t come back.

I would love to do that. Only I can’t. Like the many other recurring conditions we treat every day, nothing specific causes eczema, so nothing definitive gets rid of it once and for all.

In other words, eczema has no butt. So you can’t kick it.

The examples I’ve given are common and homely. There are bigger issues, in medicine and in life, to which common-sense maxims seem to apply but sometimes don’t.

The well-known public debates over prostate-specific antigen (PSA) screening for prostate cancer in older men and routine mammography in younger women attest to how tricky it is to decide whether catching things early is necessarily a good idea. It also shows how the public reacts when data contradict common sense. Of course you should catch cancer early, says the outraged public. Isn’t it always better to be safe than sorry?

No, actually it sometimes isn’t.

We all pick up maxims to live by. We hear them as children without realizing we’re learning them. That makes it hard to accept that not everything is a plant with a bud to be nipped. Or that there are situations when trying to be safe can make you sorrier.

Or that there are indeed butts, big and small. But not everything has one to kick.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

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