Listening is hard. Often, you only hear what you expect to hear.
“Did you hear what he said about the golf ball?”
My student looked blank. Our patient had just come in for an annual skin check. “Golf ball?” asked the student.
I told him that the patient said he was hit by a golf ball.
“You’re right,” said the student. “He did say that.”
“Why did he tell me he was hit by a golf ball?” I asked. The student couldn’t recall.
“He was pointing to a red spot on his forehead I was looking at,” I reminded him. “I said it was a precancerous sun spot that I could freeze off with some liquid nitrogen.”
“Yes,” said the student. “Now I remember.”
“Good,” I said. “Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But he’s 60 years old. He’s been hit by lots of things. Maybe a golf ball did hit his head, but how can he be sure it was in exactly that spot? And even if he is sure, why tell me about it?”
Seeing his befuddlement, I decided to help the student out. “He must have thought it was important for me to know while I was examining that spot,” I said, “but why would he think that I’d find that particular golf ball incident useful? You and I talked about this the other day.”
“You mean because it was trauma?”
“You got it,” I said. “One of the ways patients explain to themselves why things happen to them is that whatever part of them is sick got hit by something. They think that trauma weakens and damages the body—or the skin part—and makes it prone to being unhealthy.
“After all,” I went on, “I had told him it was a ’sun spot’, meaning it was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot right there? I don’t know why myself, so he supplies his own answer. This a story he’s been telling himself since before he can remember. Sure, sun damages skin in general, but it was just the skin that got whacked by a golf ball that became more susceptible than anyplace else. Or so he thinks.
“Is he right?” I asked. “I actually have no idea, but it’s important—to him—that he thinks it is. Not so much for this spot—we’re going to treat it anyway—but because of what he said two minutes later about his left shin. Do you remember what that was?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just an age barnacle, not even precancerous. The problem was that he is always picking at it.”
“Yes,” said the student. “Now that you mention it, he did say that.”
“Why was that important for him to say?” I asked. “Why did he think I needed to know?”
“Because picking it is in the form of trauma, and that might cause the spot to develop into something?”
“Now you’re getting it,” I said. You should train herself to listen to these offhand remarks that don’t seem to have anything to do with what you’re interested in but are very much what the patient is interested in.
“How many people come here to ask me to take something off ‘because I keep picking at it’? Or because ‘it rubs on my necklace’ or ‘it rubs on my bra’? If you think it’s just annoyance, think again, especially when you see that the spots in question are often not even close to what is supposed to be irritating them, or else they’re so small that you can barely see them.”
Sure enough, a little later the student and I walked in to another patient who came in for an annual full body check. This gentleman, by the way, is a computer scientist from a major local university. He has a large number of cherry angiomas, collections of red blood vessels that run in families and tend to be mostly on the middle of the body, from the neck to the thighs.
This fellow had quite a large collection of them spending his whole torso and abdomen, front and back.
As I examined his belly, he said,” I know where I got those.”
“Which ones? I asked.
He pointed to a particularly dense collection of red spots around his navel. “I got hit by a soccer ball there when I was a teenager down in Colombia,” he said.
When we are alone later, I pointed out this to the student: “What made this gentleman’s observation striking is not just that it’s another example of somebody blaming body changes on trauma. It’s that he did so in a way that even a smidgen of critical thinking would show that that his hypothesis made no sense. After all, he has lots of red spots above and below the area where the ball supposedly hit him.
“You’d think a computer scientist would notice this, but when it comes to looking at your own health, , even sophisticated scientific training, really doesn’t help much. “I’ve got these those red spots,” you tell yourself. “Something caused them. I got hit by a soccer ball somewhere around there. That must be it.”
Sometimes hearing what patients say doesn’t makes no practical difference: we’re not going to take off what they think got hit by a golf ball anyhow. But sometimes it does matter, by telling us the real reason they want something removed, which may include some guilt they don’t need that they caused their own problem by picking at it.
But you have to listen for what people say, and listening is hard. Mostly, in medicine and in life, we only hear what we expect to hear.
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. The 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.