Second Impressions

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.