Practicing medicine without judgment


“What do you think of all this election stuff?” I froze. Sitting on the exam table was a 50-something-year-old woman. Her hair was long, but not gray. She was wearing a mask without distinctive markings, such as Trump lips or #BLM to identify the political leanings of the owner. She had a subtle New York accent, perhaps dating back to the Giuliani years. It was hard to know her intention. “It’s a trap!” I could hear Admiral Ackbar’s voice in my head. “Don’t engage.” We all know nothing erodes trust faster than showing your blue or red colors before you know which your patient identifies.

Instead, I replied that indeed it has been a stressful year for us all. Then I paused. She shifted a bit and tugged at the gown sleeves and admitted this was the most stress she felt in years. She was seeing me for lichen sclerosus et atrophicus, a terribly itchy, sometimes-disfiguring eruption that can occur in the vulva. She was dealing with COVID-19, kids, divorce, a new partner, working from home, parents, and now the election drama.

At this point in the visit, I knew I could help her. First, the treatment for lichen sclerosus is straightforward and mostly effective. Second, I knew I’d have 7 minutes to spare to just listen. It was a lucky break, as often no such gift of time presents itself while seeing patients in a busy clinic. We take vitals, history (typing), do an exam, make a diagnosis (more typing), and maybe a procedure (yet more typing). All of this is necessary, but sometimes not what our patient needs. Some really need just to connect and share their burden with someone who isn’t a friend or family. As physicians, we have a unique opportunity to see and hear people without judgment.

This reminds me of a recent episode from Sam Harris’s podcast, “Making Sense.” Mr. Harris, a philosopher (and “blue” all the way through) revealed his insight into Presidents Trump’s appeal. Leaving policy aside, Mr. Harris notes that people are drawn to the President because he never judges you. He is incapable of being sanctimonious, Mr. Harris argues, and therefore creates a safe space for people to continue their lives, however flawed, without expectation that they improve.

I’m unsure just how much of this theory explains the devotion of his supporters, but it resonated with me. We doctors are sanctimonious by nature. The better part of my day is spent prodding people to be better: Wear more sunscreen, exercise more, stop believing in conspiracy theories, get your flu shot, and above all, stop scratching! In doing so, I’m in a way judging them. Finger wagging: You’re lazy or poor or dumb or stubborn. “You aren’t as good as me,” is what they might feel after 15 minutes of my pep talk.

But what if that’s wrong? What if they are just fine exactly the way they are? Perhaps what my lichen sclerosis patient needs more than anything is unconditional attention? She, like most of our patients, is well aware of how her shortcomings might contribute to her own anxiety or difficulties. And now she has this rash and that’s probably somehow her fault too, she thinks.


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