Rational Actors

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.