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Teaching and Learning Moments

Beyond the Chief Concern

Saklecha, Anokhi

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doi: 10.1097/ACM.0000000000003585
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“Every night I fall asleep in complete terror of what I’ll wake up to.”

The patient was in her early 30s. Her eyebrows began to furrow as tears gently streamed down her cheeks.

She had vitiligo, but at first glance, you wouldn’t guess it. As I walked into the room for the first time, I was excited to see that her skin was so clear, especially compared with previous patients we had seen. “Her medications must be working well,” I thought. When the dermatology attending shared this same assessment with the patient, she unexpectedly responded with doubt and distress.

Though she manifested only 2 pea-sized lesions, the emotional burden of her condition was evident in her expression. As we later discovered, she spent every free hour on online vitiligo forums and went to bed each night fearing an eruption of patches the next day.

With his arm on the patient’s shoulder, my attending took a seat, and what I thought would be a 10-minute appointment soon transformed into a 45-minute encounter. After recognizing the patient’s anxieties, he took a moment to ascertain the personal consequences of her vitiligo—how it was affecting her sleep, marriage, diet, and routine. He then went on to clarify the pathophysiology of the disease, refining her own knowledge while dispelling misconceptions. The furrows in the patient’s forehead gently disappeared as traces of hope returned.

We then moved to the computer as my attending began discussing ongoing clinical trials, emerging biologic drugs, and online support groups for vitiligo. He explained that the patient’s disease was under control now, but if it did progress, there would be options available to her. By the end of the conversation, her eyes had welled up again, but this time, she assured us they were tears of gratitude. While all of the patient’s concerns were not magically reversed, she expressed her relief and appreciation and assured us that she would keep us updated on her condition––both physical and emotional.

When I later expressed my surprise at the depth of that encounter compared with the prior 12-minute skin cancer appointment, my attending simply reminded me that we were there to treat the patients and not their diseases.

The truth is, physical health is inextricably attached to the mind. It affects quality of life, emotional courage, and self-identity. While this patient’s disease was objectively improving, her health was not, and it was our duty to fix that. Part of this effort required patient education; however, the other part simply entailed being human—listening to her concerns, validating her feelings, and holding her hand.

Studies have shown that up to 60% of dermatology patients face an associated psychiatric disorder, with similar statistics in other fields. However, these mental health conditions manifest in a range of ways. The severity of a diagnosis does not always align with the physical state of a patient, and certainly not with the length of an appointment. Every patient is different, and we should do our best to resist comparisons.

As a medical trainee, I aim to put this principle into practice as I begin to treat patients—looking at them holistically and transcending their chief concerns—to topics involving well-being and lifestyle. With this patient, we were lucky that she chose to voice her anxieties. I can only imagine the number of patients who suppress similar feelings while displaying a tough exterior.

It is my hope that we can offer a hand to such patients in need, reserving our judgments and suspending our conclusions. After all, treating the patient is more than just skin deep.

An Academic Medicine Podcast episode featuring this article is available wherever you get your podcasts.

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