Archive for December, 2014

List Making, Neurotic Behavior? La Maladie du Petit Papier

Monday, December 15, 2014 // Uncategorized

This is a perspective from last weeks The New England Journal of Medicine that was pointed out to my by a former 4th year medical student, James Saca, AMD (almost a doctor).  It was prompted by my quoting the 1985 article(my how time flies!) mentioned below.  It deals with the issue of whether list making by patients is a form of neurotic behavior.  Thank you James!


The Disease of the Little Paper

Suzanne Koven, M.D.

N Engl J Med 2014; 371:2251-2253December 11, 2014DOI: 10.1056/NEJMp1411685


Toward the end of his life, my father tried to engage me in conversations about our shared profession. He presided over these sessions from an armchair, his legs tucked under a blanket against the air-conditioned Florida chill to which he’d retired.

“Seen any great cases?” he’d ask. This question set my teeth on edge. Our relationship hadn’t been easy when I was young, and even well into middle age as I was then, it didn’t take much to fan the embers of my adolescent anger.

I’d explain — again — that I was a general internist, not a specialist as he had been, and derived my professional satisfaction from long and close relationships with patients and not from making obscure diagnoses.

He would give me a pitying look and shrug. Then he’d tell me some anecdote in which I heard him imply that he was more resourceful, wiser, and more devoted to and beloved by his patients than I could ever hope to be. About how, during the war, he recycled penicillin from patients’ urine and injected it into other patients. About how, during a housekeepers’ strike, he mopped floors and folded sheets and towels in the laundry room of the hospital where he was chief of staff.

The reminiscence I bristled at most, though, was about ladies — always they were “ladies” — with something he called la maladie du petit papier: the disease of the little paper. They would come to his office and withdraw from their purses tiny pieces of paper that unfolded into large sheets on which they’d written long lists of medical complaints.

“You know what I did then?” Dad asked. I did, but I let him tell me again anyway. “I’d listen to each symptom carefully, and say `yes’ or `I see’ — that’s all. And when a lady finally reached the end of her list, she would say, `Oh doctor, I feel so much better!’ The point is, all those ladies needed was someone to listen.”

After my father died, I researched some of the things he’d mentioned to me. Data collection was crucial to my mourning process. I longed for evidence of my father other than my own memory of him. I wanted — irrationally, I know — written proof that he’d existed.

An article in Time magazine, dated September 11, 1944, reported a novel extraction method whereby 30% of the penicillin injected into one patient could be reclaimed from the urine and injected into another patient. Doctors at a military hospital on Staten Island, facing a shortage of the wonder drug, were using this technique in enlisted men with gonorrhea.

An American history website featured an interview with a labor activist who had organized low-paid hospital workers to strike in New York City in the 1970s.

I found la maladie du petit papier, too. It’s defined, in an online medical dictionary (, as a condition in which “an exhaustive list of purported ailments — [is] carried around by a neurotic patient, often accompanied by extensive documentation of each bowel movement or sip of water.” The term, probably coined in the clinic of Jean-Martin Charcot at the Salpêtrière in the late 19th century, has never been complimentary. In an anti-Semitic treatise, one disciple of Charcot described a Jewish list-maker with scorn. He wrote, “In a voluminous batch of filthy scraps of papers that never leaves him, he shows us prescriptions from all the universities of Europe and signed by the most illustrious names.”1 Sir William Osler was more restrained but no less dismissive. He observed, “A patient with a written list of symptoms — neurasthenia.”2 In recent years, one doctor updated the diagnosis to “la maladie du grand print out,” a nod to the indispensability of the Internet to the modern hypochondriac.3

In a 1985 Journal article, primary care internist John F. Burnum challenged the notion that the disease of the little paper is a disease at all. He reported the results of an informal study he conducted in his own practice. Of 900 patients he saw in a 4-month period, 72 (8%) brought in lists of concerns. Burnum observed no higher incidence of mental illness and no lower incidence of physical illness in his list-making patients than in the non–list-makers. He concluded that patients who make lists aren’t neurotic, but simply “seeking clarity, order, information, and control.”4

Of course I was familiar, from my own practice, with the phenomenon of patients making lists, but I’d never known it had a name. I confess that these lists sometimes irritate me, as they do many doctors. Especially irksome is the sight of my last name without my title, scrawled at the top of a list — evidence that to my patient I am often merely another stop in a series of tedious errands guided by similar lists headed “GROCERIES” or “TO DO.” I steal an upside-down glance, in hopes that the list will be short, or at least that we’ll have covered most of the items by the time the little piece of paper makes its appearance. Each checkmark floods me with relief: “Prescriptions, you filled them. . . that mole on my thigh, you looked at it . . . we talked about that weird dizzy thing . . . .”

Why should these little pieces of paper bother me? I know that often patients, sensibly, bring lists to make the most of hard-to-schedule and ever-shorter visits with their doctors — indeed, in recent years they’ve been encouraged to do so. I’m aware of the studies that show the mere act of jotting symptoms down can ameliorate them. As a writer, I surely understand the urge to put pen to paper.

I wonder if I resent these lists because they threaten me. The “control” that Burnum thought patients reasonably sought is wrested, in part, from the doctor. When a patient pulls out that little piece of paper, I feel a shift in the exam room: the patient taking charge of the agenda, my schedule running late, the reins of the visit loosening in my hands.

I’m ashamed of my resentment, which is as unjustified as it is unbecoming. I know these lists aren’t really threats to me. They’re not about me at all. They are, like all writing, forms of self-expression. I remember the mathematician who handed me spreadsheets of his blood pressures with the mean and standard deviation calculated; the flamboyantly dressed woman who favored hot pink clothing and penned her lists in ink to match; the savvy businessman, many years ago, who clicked through his list on an early mobile device.

It turns out that my father was right: often, even when I have no explanation for the headache, upset stomach, or itch documented on the back of an envelope or punched into a smartphone, a patient feels better just having presented me with his or her recording of it. Perhaps naming our demons and saying their names aloud helps make them less frightening. Perhaps the shorthand of the list somehow abbreviates the anxiety associated with its entries.

Or maybe lists bring still deeper comfort. Concerns set in ink are made concrete, less likely to be ignored. Those little pieces of paper are declarations: I’m human, and my suffering is real. Writer Susan Sontag, a self-described compulsive list-maker, might have agreed. She once wrote that in writing lists, “I confer value, I create value, I even create — or guarantee — existence.”5

Strange that writing this, 10 years after my father’s death, makes me miss him more, yet also lessens the pain of missing him. Sometimes a lady really does just need someone to listen.

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Source Information

From Massachusetts General Hospital and Harvard Medical School — both in Boston.

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Do The Clothes Make the Doctor?

Sunday, December 7, 2014 // Uncategorized

One of my patients went to a new neurologist accompanied by his wife who was shocked at how provocatively dressed the woman physician was and asked me to recommend them to someone else.

The Clothes Make the Doctor

By Anna Reisman

A few years ago, I was looking for a new primary-care doctor. I was hoping for someone who was kind, smart, and caring, someone who’d listen with full attention. I didn’t care what the doctor looked like—or so I thought, until a woman clicked into the room in stilettos and a tailored expensive-looking suit. This wasn’t a case of a low-cut blouse or a thigh-revealing skirt. And yet I felt put off. I felt like a slob. The doctor was nice enough, perhaps a little brusque, or maybe her clothes were brusque, and I didn’t end up sticking with her. What I remember most was the feeling that she had somewhere more important to be, like a board meeting, where the discussion would involve the business of medicine rather than the art of it.

Maybe it wouldn’t have bothered me if I were meeting her at the Mayo clinic, where all doctors wear business suits—a uniform, really—where I would have expected it. Or if she were a cosmetic surgeon, a field where it behooves a doctor to look chic and well-coiffed, with skin as silken-smooth as the ubiquitous subway skin doctor Jonathan Zizmor. But primary-care medicine is a different beast, where it’s less about a couple of visits for Botox and more about the relationship between doctor and patient, which ideally will last for years and years.  And what the doctor wears—part of the patient’s first impression—can have an effect.

In medical school, students learn to note a patient’s appearance and clothing (words like “disheveled” or “well-groomed” seem to pop up a lot in the medical record).  They’re taught to interpret the patient’s gestures and eye contact, or lack of it, and to think about their own body language.  And yet, somehow, the topic of doctors’ own clothing rarely comes up, save for the most flagrant lapses (plunging necklines, jeans, T-shirts) or the simple and vague admonition to appear “professional.”

“Professional” is a tricky word in a clothing context. It’s possible, of course, that other patients found the stiletto doctor’s business attire entirely appropriate, a reassuring hat-tip to the doctor’s traditional stature. In days of yore, the doctor was clearly identifiable by the white lab coat over shirt and tie, his agreeable nurse counterpart unmistakable in white dress and cap (which, depending on one’s school, might be shaped like a coffee filter, sailor’s cap, or a hamantaschen).  But in the 21st century, especially in primary-care medicine, much has changed; with more categories of clinicians (nurse practitioners, physician assistants) in every sphere of medicine, the traditional clinical clothing boundaries have blurred.

The definition of what counts as professional clothing is also in flux, thanks to increasing knowledge of infectious risks. Earlier this year, the Society for Healthcare Epidemiology Association (SHEA) published new guidelines for healthcare-personnel attire in hospital settings. Their goal was to balance the need for professional appearance with the obligation to minimize potential germ transmission via clothing and other doodads like ID badges and jewelry and neckties that might touch body parts or bodily fluids. The SHEA investigators’ take-home points regarding infection: White coats should be washed weekly, at the minimum; neckties should be clipped in place (70 percent of doctors in two studies admitted to having never had a tie cleaned); and institutions should strongly consider a “bare below the elbow” (BBE) policy, meaning short sleeves and no wristwatches or jewelry. Although the impact on reducing the risk of infections remains to be determined, it’s considered potentially significant enough that a number of countries have adopted BBE requirements for all clinicians. (And it leaves me wondering: When will the Mayo clinic update its dress code to short-sleeved business suits?)

The report also addressed the question of what patients want their doctors to wear. The short answer from the SHEA investigators, who reviewed 26 studies of patient perceptions of doctors’ clothing, was that patients prefer that doctors appear “formal” rather than “casual.”  But forcing all clothing-description categories into one or the other of those two somewhat vague terms is misleading. Here’s why: In those studies (including one that was satire and shouldn’t have been included), there were abundant ways of describing clothing with so many different scales and definitions of formal versus casual it would make your head spin. Consider a few of the many systems for categorizing outfits: A man’s shirt and tie was “formal” in one study, “semiformal” in another, and elsewhere “business” and “professional informal.” A woman’s dress or skirt was “formal” in one, “business” in another. Slacks and a pullover shirt or blouse: “casual” in one, “smart casual” in another.

Perhaps the proper conclusion is that there is no one “right” way for doctors to dress. While every patient wants their doctor to look decent, there’s a range of what’s acceptable, and context matters. Facial expressions and body language communicate as much as words; clothing, similarly, should blend seamlessly with a doctor’s ability to emanate trustworthiness, competence, and caring. During a visit to a patient at a local hospice, I was struck by one of the doctor’s outfits: He dressed simply but neatly, in brown corduroy pants and a sweater vest, his sleeves rolled to the elbow. His clothes gave one the sense that he had all the time in the world to schmooze with his patients and their families.

I suspect that he chose those clothes because they made him feel that way, too, like he could kick back, put his feet up on the windowsill, and just be there, for as long as it took. There’s a term for the way that clothing and physical sensations trigger abstract concepts: embodied cognition. A few Halloweens ago, when I dressed as Sarah Palin in a close-fitting suit, lots of red lipstick, my hair piled in an aggressive teased bun, I felt brash and bumptious. Perhaps the stiletto-wearing doctor felt similarly bolstered by her designer duds; perhaps it was her way of surviving in a world that gives more power to her male colleagues. But we doctors present different sides of ourselves to colleagues and patients, and more down-to-earth clothes can diminish the power differential between provider and patient and make the process of connection easier.

Last week, two days in a row, I ran into a colleague who’s a pediatrician. The first day, she wore a beige pantsuit (I’d label it formal, or business) and looked fairly corporate. I wondered to myself if she realized that her clothes were sending a message to her patients, a message that indicated that her medical practice was a business and that she wielded the power. The next day, she wore a loose-fitting knee-length navy dress (professional informal, perhaps, or smart casual). I asked her if she had seen patients the first day. She had not; it was a day of meetings, and when I told her I was writing about doctors’ clothing, she laughed. “When you’re seeing patients,” she said, “you have to look like you’re not afraid to get dirty.”

Would the stiletto-wearing doctor squat down to examine a sore on a wheelchair-bound patient’s foot, or roll up her linen sleeves in preparation for a Pap smear? I suppose she would. But I’d rather see someone whose clothes didn’t leave me wondering. Give me a warm-hearted doctor with an open, interested expression, and I might not even notice what she’s wearing.

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