Under My Skin

But you told me...


“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”

I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.

In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.

Dr. Alan Rockoff

Dr. Alan Rockoff

“You saw that mole when I was last here 5 years ago,” says Steve. “You said we should keep an eye on it.”

No, I didn’t.

I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?

That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.

Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.

Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”

Nope, not even close.

What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?

The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.

“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”

Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.

No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”

Philip nods. I think he understands. But I thought so last time too, didn’t I?

I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”

No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.

Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.

I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.

I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”

That was clear. I think.

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. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].

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