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Practicing medicine gives you the chance to ask many questions you never thought you’d have to consider, like the one that gives this blog its title.
Frank came by the other day. He was very anxious. He had a rash on his penis that was itchy, and very worrying. For more than a month he had tried anti-fungus creams, both over-the-counter and prescribed by his primary physician, but the rash was still there.
“I’m happy to tell you that this is not a fungus,” I told him. “It’s just eczema, sensitive skin. Maybe someone in your family has it, but it doesn’t matter. It’s not catchy—you didn’t pick it up from someone, and you can’t transmit it to anybody else. I’ll give you a cream that should clear it up in a couple of days. It may come back once in a while, but if it does, you can make it go away in a day or two.”
Frank looked relieved, but only a little.
What about this blue line in my groin?” he asked.
“That’s just a blood vessel,” I said, “near the surface of the skin.”
“It wasn’t there before,” he said.
“I think it probably was,” I said. “Maybe you never noticed.”
“But how about these little white bumps near the blue line?”
“Those are small cysts,” I said. “They’re common in the groin area. See, you have some on your scrotum too.”
“I never had them before,” he said.
“They were probably there,” I said. “You just never noticed.”
“But I never saw them till now,” said Frank.
I sighed a little, to myself. I’ve lived this scenario before.
“It’s only natural that you wouldn’t notice them,” I told him. “Who looks at their groin? At least until you get a rash or something that draws your attention to the area. Then you look all the time. Am I right?”
Frank nodded, a little sheepishly.
“How often do you look down there now?” I asked him. “A dozen times a day?”
“At least,” he said, finally smiling a little.
You don’t have to be neurotic or obsessive to stare compulsively at a part of your body. All you have to be is scared. Then you can’t stop looking at whatever you’re scared about. And when you look often and hard, you start seeing things. Not things that aren’t there—things that are there. They’ve been there who knows how long, but how would you know if you’ve never looked. And why would you look?
This may sound obvious, but there’s nothing obvious about it when you’re worried about something. Many kinds of symptoms will do that to people, but rashes in groins, for reasons too obvious to explain, are a prime example.
In dermatology, other examples are endless: That mole—was it always there looking that way, or did it change? That rash—I can’t remember having it before. That bruise—I can’t remember hitting myself or anything. That lump under the skin—was that there before?
The same is true for other kinds of symptoms: aches, pains, cramps, itches. Once you notice them, it’s as hard to get them out of your mind as it is to not smile when somebody tells you not to.
The fancy term for this is “hypervigilance.” But deciding which vigilance is “hyper”—how much is too much—depends on the diagnosis, the symptoms, a person’s natural temperament, and lots of other things. Sometimes watching out carefully is important to do. Other times, it’s counterproductive. You would be amazed at the kinds of symptoms and fears our brains can invent to scare the daylights out of use once we’re worried enough to focus on something.
One challenge physicians have is to figure out what is making people examine themselves too much or too hard, and convince them they don’t need to. Some patients are hard to convince. After all, I don’t have access to a time-lapse video of Frank’s groin to prove to him that the bumps have been there forever.
But he seemed to be calming down at my reassurance, so I told him what I like to say under these circumstances, when I think I can get away with it.
“Don’t look down,” I said. “What you’ve got down there belongs down there.
“From now on, Frank, look up!”
Frank grinned. A relief—for both of us.
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Dr. Rockoff’s new book, Act Like a Doctor, Think Like a Patient: Teaching Patient-Focused Medicine has just been published by Medical Education Press. This book focuses on the need for medical providers to know not just how to diagnose and treat disease, but to understand patient and make them feel better. You can order the book on Amazon.
https://www.amazon.com/Like-Doctor-Think-Patient-Patient-Focused/dp/194…
