Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.
"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.
There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.
This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.
We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")
Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.
For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.
Even light-related changes that have nothing to do with cancerphotosensitivity from doxycycline, for instancecause concern, because "they came right after sun exposure."
Patients who have moles that look funny to them (like halo nevi)or which someone has told them to "keep an eye onmay take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boommoles cancerize.
Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.
The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:
"What are these crusty spots, Doctor?"
"Solar keratoses, Mrs. Goldfarb. They're from the sun."
"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")
Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.
Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.
Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.
No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.