Listening Between the Lines

You only hear what you listen for.

When people say things that seem to make no sense, our natural reaction is to ignore the statements or let them pass unnoticed. But filtering out seemingly nonsensical remarks from patients can be a mistake, because offhand comments reveal a lot about how they see the world, which is often quite different from the way we see things.

Consider Harriet: "My mole changed because it's near my bra strap," she said.
The mole is irregular, not irritated, so why does Harriet think her bra had anything to do with it? When I asked my students this question, they looked blank. "Did she really say that?" they asked. They didn’t really hear my question, because the statement made no sense to them.

But it made sense to Harriet. What she meant to say was: "Trauma causes cancer." Of course we know that trauma does not cause cancer, but Harriet thinks it does, and she has a lot of company.

"These spots on my nose came when my face hit a window," said Bill. Does it matter if he believes this?

Consider Cindy: "My brother picked at a spot on his cheek, and he died," she said. Yes, people really do say things like this, all the time. You just have to listen for them. Here is what else they say:

"Does Fiona have to take extra precautions in the sun for the moles on her back by covering them up?" asked her mother. Why did she ask this? Because sunburn is a form of trauma, and everybody knows what trauma can do. So what if she thinks this, right?

She insisted that Fiona cover her moles with bandages at the beach. Sound silly? Fiona’s mother didn’t think so. Ask her. Better still, volunteer that Fiona can stop putting bandages on her moles, and watch mom beam with relief or astonishment. "But that’s what I've been doing!" exclaimed Fiona.

Then, there is  Barry: "I think I'm getting acne because of the water at my new school." Barry is from Chicago. At this very moment in Chicago, another Barry – from Boston – is telling his dermatologist that it must be the Midwestern water. Why do they each think so?

"The water” (or "the air," or "the atmosphere," or "the environment") has explained disease since Hippocrates. Everybody knows this. You can hear them say so, if you listen.

"It's the weather," they say, or the change of seasons, or the power lines.
Or take Gerrold, who had a cluster of bumps on his left elbow and knew why: "The pustules on my arm are my body trying to get rid of something." How's that? What is your body trying to get rid of?

It seems his body was trying to expel evil,  noxious stuff, just as it does when eliminating other unpleasant body fluids. These include sebum, which is why so many work so hard to cleanse their pores. We must get that bad stuff out.
"Tell me," I asked my student, "why the last patient said his cherry angioma is gross?"

"Did he say that?" asked the student, looking perplexed.

He did. The student didn't hear him, because there seems to be no room for the word "disgusting" in a medical interaction. A lesion can be benign or malignant, but not disgusting. Yet the patient, a middle-aged electrician, said, "When I was leaving the house to come here, my kids said, 'Dad, get rid of that gross thing!' "

So did Paula, a 20-something concerned with a bump on her scalp. "My boyfriend said, 'That’s disgusting!' " I told Paula it was a benign mole. "Maybe so," she said, "but it's disgusting."

The question is not whether we need to agree that skin irregularities are repugnant, but why patients announce they think so. They say this not just about oozing or contagious dermatoses but about harmless lumps and bumps. Why?

Perhaps these spontaneous outbursts of distaste tell us that what people think about skin problems goes beyond functional disability, and that distinctions between "medical" and "cosmetic" can be arbitrary and beside the point.

That may not be very meaningful to us, but like everything else we ought to know about patients,  it makes a lot of sense to them. They tell us so over and over. But to hear them, we need to listen between the lines.

You only hear what you listen for.

When people say things that seem to make no sense, our natural reaction is to ignore the statements or let them pass unnoticed. But filtering out seemingly nonsensical remarks from patients can be a mistake, because offhand comments reveal a lot about how they see the world, which is often quite different from the way we see things.

Consider Harriet: "My mole changed because it's near my bra strap," she said.
The mole is irregular, not irritated, so why does Harriet think her bra had anything to do with it? When I asked my students this question, they looked blank. "Did she really say that?" they asked. They didn’t really hear my question, because the statement made no sense to them.

But it made sense to Harriet. What she meant to say was: "Trauma causes cancer." Of course we know that trauma does not cause cancer, but Harriet thinks it does, and she has a lot of company.

"These spots on my nose came when my face hit a window," said Bill. Does it matter if he believes this?

Consider Cindy: "My brother picked at a spot on his cheek, and he died," she said. Yes, people really do say things like this, all the time. You just have to listen for them. Here is what else they say:

"Does Fiona have to take extra precautions in the sun for the moles on her back by covering them up?" asked her mother. Why did she ask this? Because sunburn is a form of trauma, and everybody knows what trauma can do. So what if she thinks this, right?

She insisted that Fiona cover her moles with bandages at the beach. Sound silly? Fiona’s mother didn’t think so. Ask her. Better still, volunteer that Fiona can stop putting bandages on her moles, and watch mom beam with relief or astonishment. "But that’s what I've been doing!" exclaimed Fiona.

Then, there is  Barry: "I think I'm getting acne because of the water at my new school." Barry is from Chicago. At this very moment in Chicago, another Barry – from Boston – is telling his dermatologist that it must be the Midwestern water. Why do they each think so?

"The water” (or "the air," or "the atmosphere," or "the environment") has explained disease since Hippocrates. Everybody knows this. You can hear them say so, if you listen.

"It's the weather," they say, or the change of seasons, or the power lines.
Or take Gerrold, who had a cluster of bumps on his left elbow and knew why: "The pustules on my arm are my body trying to get rid of something." How's that? What is your body trying to get rid of?

It seems his body was trying to expel evil,  noxious stuff, just as it does when eliminating other unpleasant body fluids. These include sebum, which is why so many work so hard to cleanse their pores. We must get that bad stuff out.
"Tell me," I asked my student, "why the last patient said his cherry angioma is gross?"

"Did he say that?" asked the student, looking perplexed.

He did. The student didn't hear him, because there seems to be no room for the word "disgusting" in a medical interaction. A lesion can be benign or malignant, but not disgusting. Yet the patient, a middle-aged electrician, said, "When I was leaving the house to come here, my kids said, 'Dad, get rid of that gross thing!' "

So did Paula, a 20-something concerned with a bump on her scalp. "My boyfriend said, 'That’s disgusting!' " I told Paula it was a benign mole. "Maybe so," she said, "but it's disgusting."

The question is not whether we need to agree that skin irregularities are repugnant, but why patients announce they think so. They say this not just about oozing or contagious dermatoses but about harmless lumps and bumps. Why?

Perhaps these spontaneous outbursts of distaste tell us that what people think about skin problems goes beyond functional disability, and that distinctions between "medical" and "cosmetic" can be arbitrary and beside the point.

That may not be very meaningful to us, but like everything else we ought to know about patients,  it makes a lot of sense to them. They tell us so over and over. But to hear them, we need to listen between the lines.

You only hear what you listen for.

When people say things that seem to make no sense, our natural reaction is to ignore the statements or let them pass unnoticed. But filtering out seemingly nonsensical remarks from patients can be a mistake, because offhand comments reveal a lot about how they see the world, which is often quite different from the way we see things.

Consider Harriet: "My mole changed because it's near my bra strap," she said.
The mole is irregular, not irritated, so why does Harriet think her bra had anything to do with it? When I asked my students this question, they looked blank. "Did she really say that?" they asked. They didn’t really hear my question, because the statement made no sense to them.

But it made sense to Harriet. What she meant to say was: "Trauma causes cancer." Of course we know that trauma does not cause cancer, but Harriet thinks it does, and she has a lot of company.

"These spots on my nose came when my face hit a window," said Bill. Does it matter if he believes this?

Consider Cindy: "My brother picked at a spot on his cheek, and he died," she said. Yes, people really do say things like this, all the time. You just have to listen for them. Here is what else they say:

"Does Fiona have to take extra precautions in the sun for the moles on her back by covering them up?" asked her mother. Why did she ask this? Because sunburn is a form of trauma, and everybody knows what trauma can do. So what if she thinks this, right?

She insisted that Fiona cover her moles with bandages at the beach. Sound silly? Fiona’s mother didn’t think so. Ask her. Better still, volunteer that Fiona can stop putting bandages on her moles, and watch mom beam with relief or astonishment. "But that’s what I've been doing!" exclaimed Fiona.

Then, there is  Barry: "I think I'm getting acne because of the water at my new school." Barry is from Chicago. At this very moment in Chicago, another Barry – from Boston – is telling his dermatologist that it must be the Midwestern water. Why do they each think so?

"The water” (or "the air," or "the atmosphere," or "the environment") has explained disease since Hippocrates. Everybody knows this. You can hear them say so, if you listen.

"It's the weather," they say, or the change of seasons, or the power lines.
Or take Gerrold, who had a cluster of bumps on his left elbow and knew why: "The pustules on my arm are my body trying to get rid of something." How's that? What is your body trying to get rid of?

It seems his body was trying to expel evil,  noxious stuff, just as it does when eliminating other unpleasant body fluids. These include sebum, which is why so many work so hard to cleanse their pores. We must get that bad stuff out.
"Tell me," I asked my student, "why the last patient said his cherry angioma is gross?"

"Did he say that?" asked the student, looking perplexed.

He did. The student didn't hear him, because there seems to be no room for the word "disgusting" in a medical interaction. A lesion can be benign or malignant, but not disgusting. Yet the patient, a middle-aged electrician, said, "When I was leaving the house to come here, my kids said, 'Dad, get rid of that gross thing!' "

So did Paula, a 20-something concerned with a bump on her scalp. "My boyfriend said, 'That’s disgusting!' " I told Paula it was a benign mole. "Maybe so," she said, "but it's disgusting."

The question is not whether we need to agree that skin irregularities are repugnant, but why patients announce they think so. They say this not just about oozing or contagious dermatoses but about harmless lumps and bumps. Why?

Perhaps these spontaneous outbursts of distaste tell us that what people think about skin problems goes beyond functional disability, and that distinctions between "medical" and "cosmetic" can be arbitrary and beside the point.

That may not be very meaningful to us, but like everything else we ought to know about patients,  it makes a lot of sense to them. They tell us so over and over. But to hear them, we need to listen between the lines.