Wednesday, August 7, 2013

Life threatening vs. Quality-of-life threatening.

Help me help you. Or rather help you help me.

What bothered you was simple. A big, dry patch of skin on your leg that was itchy and uncomfortable. Even with your self-prescribed remedies, that affected area was getting bigger and, to quote you, "worser." And no. This wasn't something that was life threatening by any stretch of the imagination. But you didn't care about that because to you it was quality-of-life threatening. Which at eighty something years old is perhaps more unacceptable than the former. 

Here's what was bothering us. Your cholesterol level was high. Too high for us to shrug off when you said with eye lids at half mast that, "Naaw, I ain't tekking no extra pills no matter what it's for." So instead of taking no for an answer, we tried to explain why this pill to reduce your LDL was a good idea. 

"It will protect you from heart attack and stroke, sir," my resident said. "That's important."

"And you are very independent, sir," I chimed in. "We should always do all that we can to lower that risk. With you having diabetes, too, it's really something we should do."

You shook your head hard. That let us know that you weren't interested in our closing argument for lipid-lowering agents. To underscore that, you returned to your original concern.

"So what y'all gon' do about this here?" You pulled up your pants leg again to reveal that same patch of skin. It had white stripes over it like chalk on a chalkboard from where you'd been scratching it. I raised my eyebrows when you did because to me, the diagnosis was clear.

Assessment: Dry and ashy.
Plan: Moisture.

Since I didn't think you'd like that so much, I decided to look at it more closely. Bringing my face closer I studied your leg and the skin all around it. That one area on the side of your leg had prominent hair follicles with dry whitish caps. The part surrounding it was also very parched and leathery. I wish my diagnosis could have been more exotic. But it wasn't. My assessment was essentially unchanged.

Assessment: Super-dry and super-ashy.
Plan: Super-moisture.

"You skin is really, really dry, sir. Some people call that eczema when it's a bit more extreme. Mostly, I'd say this is . . . hmmm. . .just really dry and ashy skin." I smiled after saying that word "ashy" because I thought you would, too. But you didn't. In fact, you didn't seem to appreciate me saying that one bit. 

"Ashy? Nawww. This here is more than jest ashy." You folded your arms and curled one side of your mouth upward. Your brow furrowed for a bit. Then you reached down with one of your hands to rub your leg. "This MORE than jest ashy!" 

That's when I realized that I'd hurt your feelings. Here I was being "cute" about something that was serious to you. My choice of words was trivializing and dismissed your concern. I was sorry immediately. 

"I'm sorry, sir. You're right. Let me think for a minute." I sat back in my chair and bit the side of my cheek. I wanted to allay your concern but I wasn't really sure how to do that. This didn't call for any steroid creams. It wasn't necessary to send you to a dermatologist either. But something had to be done. Something beyond just "moisture."

That's when it dawned on me that I'd missed something. Something doable and simple. Talk to you--my patient-- to build a therapeutic alliance. Instead of making fun of your concern that happened to be the least of my own.

"Let me ask you a few questions about your skin."

"Okay. Shoot."

"Do you take baths or showers?"

"I take baths. Sometime two a day." 

"Hot baths? Bubble baths?" I queried.

"Wheeewwwweeee! Hot as I can stand it. Look like when I'm off in that water it calm everything down. My joints, my muscles, and my skin. And yeah, I do put some bubbles in there. Well, really it's some kinda ol' bodywash or the other but it make good bubbles."

"I see. So two baths in a bathtub a day?"

"As opposed to two baths in where?"

I laughed when you said that. "Uhhh, as opposed to . . .yeah, that was a silly question. What kind of soap do you use?"

"Oh, I only use Ivory Soap. You know, cawse that's the purest kind."

"I'm sorry . . .did you say. . .Ivory?"

"Yes, ma'am. Tha's all I ever use. And I wash my body over two times, you know, jest in case."

I cleared my throat and blinked my eyes a few times. Your answers sounded like the kind planted for one of those standardized patient actors. You know -- the kind where they've been told all of the textbook replies to help some young medical student to make their first real-ish diagnosis.

"What about when you get out of the tub, sir? Do you put anything on your body?" I asked.

"Ma'am? Oh, yeah. I put some kinda ol' cream my daughter got me. Some ol' perfumey smelling thang in a vat from some shop in the mall." I pictured hands slathering down body butter from The Body Shop onto itchy legs. I took a big drag of air and glanced at my resident who was standing just out of your line of sight.

"So . . .let me get this straight," I recapped. "You take two hot baths in one day. You wash your body with Ivory soap. Not once, but twice. Then you use some kind of perfumed moisturizer."

"That's right. See? That's why all this itchiness on my body don't make no sense to me. Look to me like I shouldn't be itchin' nowhere."

And you know? One would think that this would be good for your skin. Especially because you seemed to be handling it with care. But the reason your resident doctor and I kept casting each other those looks was because you, sir, had given us all the information we needed to get you feeling better.

And so. I started with the baths and explained that this dried the skin out. "You know how you get out of the tub and you're like a prune sometimes?"

"Yeah!" you exclaimed with a slap of your knee. "Does that mean something?"

"Baths dry your skin out. Especially hot ones. And even though Ivory is 99.44% pure according to the commercial, it's pure soap. Which dries you out even more."

"Hush yo' mouth!"

"Nope. It strips all of the moisture out of your skin."

You nodded hard and then shook your head equally hard. You seemed gobsmacked by all of this information. "What else I'm doing wrong? I hope nothing else!" You laughed out loud when you said that because you assumed that was it. But it wasn't. Next I mentioned the perfumed lotion you were using and how this could potentially be more irritating than moisturizing.

"So what do I use to keep my skin from being dry when I get out the water?"

"You could use some good ol' fashioned Vaseline."

You swung your head over to my resident and widened your eyes for verification. "VAS-e-LINE?! I got a whole bunch of vaseline 'round my house!"


"So . . .no hot baths jest a quick shower only once, switch to some other soap like. . .what you said?"

"Dove or something like that."

"Alright then. Dove. And then some Vaseline. That's all?"

"That's all."

You smiled at me and rolled your pants leg back down. It was the happiest I'd seen you for the whole visit. I stood to shake your hand and prepare to leave. You smiled back in return.

"What was the medicine you was asking me 'bout before?" you said.

""Uuuhhhh, I'm not sure," I replied. I cocked my head at you and then snapped my finger. "Oh! You mean the statin pill for your cholesterol?"

"Yeah, that one."

"Well. We think you should take it to protect your heart and your blood vessels from a stroke." I left it there because I didn't want to prompt you to launch into a new soliloquy about the perils of polypharmacy.

You pointed over at my resident and said with a flick of your index finger, "Go on 'head and add that on."

"Really?" my resident said with his mouth wide open. "Do you mean it?"

"Yeah, yeah. Go on 'head and give me that since you think it's good for me and all."

And so we did. Because indeed we did think that. We did.

Here is what you taught me to never forget: There is power in the therapeutic alliance. That comes through first hearing the patient's agenda and honoring it no matter how straightforward it seems. Perhaps the patient who feels honored and heard is the one that feels trusting of his or her caregiver.

Just maybe.

What was bothering you was a dry patch of skin. What was bothering me was your higher than our reference range cholesterol level. Thank you for reminding me that to tackle those life-threatening problems, we often need to wade through the quality-of-life threatening ones first.


Happy Wednesday.

Dude. Pure, but it could leave you ashy and itchy. Just sayin'.


  1. You absolutely get it!

    Would've been nice to take a shortcut and tell him the dry patch was caused by high LDL to get him to take the So wrong!

    Sure wish you'd come over to Kaiser...


  2. Couldn't have been said better! You are an awesome teacher! Thank you!!

  3. From the deck of the Poop,

    Good doctoring.. the old boy didn't know exactly what was wrong but he knew it was something..



"Tell me something good. . . tell me that you like it, yeah." ~ Chaka Khan

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