Private Narratives

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.