I’m not sure that patients are any smarter than they used to be, but they certainly come pre-loaded with more facts. Sometimes these are relevant, often they are contextually unrelated to the reason for their visit. Contiguous, perhaps, yet only distantly attached –second cousins once-removed. Sometimes they seem to be variations on a word, a disease, or a belief; Google’s explanation for one symptom drawn from a bouquet of complaints –helpful maybe, but only in the setting of an accurate diagnosis of the cause: the condition responsible.
This is not to admonish the patient for trying to help, nor to disparage the often disparate droplets of assistance, but merely to acknowledge that it is possible to drown in a wading pool. Quantity does not equate to quality when it comes to facts. Nor does it equate to knowledge, unfortunately. If not intelligently –knowledgeably- selected, only some of them are flowers worth looking at; most are weeds.
But weeds are often what grow the fastest, and once they’ve taken hold, they are hard to get rid of.
“My doctor told me I have yeasts,” said Janice, the tiny woman sitting across the desk from me. She had seemed pleasant enough at first, and had even smiled at me as I shook her hand in the waiting room and led her down the corridor to my office. But once the door was closed and she was settled in a chair, her face hardened and she glared at me as if she were going to attack. She was dressed in an ankle length patterned skirt with a white blouse. It was fraying at the cuffs, but she wore it so ostentatiously that maybe it was supposed to look like that. Her brown, pony-tailed hair was pulled so tightly across the top of her head from her forehead, I wondered at first if her facial expression was because her skin was hurting. Actually, it was anger.
I had a peek at the referral letter to soften the interrogation her face was attempting. ‘Recurrent yeast infection’ it said. ‘Nothing works’. Great: an offload.
Before I could say anything, I felt the desk move as she leaned against it to sigh. “I’ve been on at least six forums about yeast, and I’m convinced I don’t have yeasts in ‘there’. She said the word ‘there’ softly, warily, so as not to shock me. “So I didn’t take any of the medications she prescribed.” Janice studied my face carefully for a reaction. I think she was disappointed I didn’t react to the dropped gauntlet.
But it was meant as a challenge. An audit. I was being screened.
I tried my best to take a history from her, but it was like trying to pry water out of a box. She knew what she had and anything else about her that didn’t directly address it she deemed irrelevant. I could understand why her family doctor had referred her. She only admitted to feeling itchy ‘down there’, and immediately closed her eyes as if she’d given away a secret. “But there’s nothing else, doctor,” she added quickly, lest I suspect some lack of regional care on her part.
I glanced at the the referral information again, but it was running a close second to Janice in disclosures. “Ahh… well, did your family doctor send off any swabs from the area?” I thought I’d better not use anatomical terms, because she hadn’t.
She eyed me suspiciously, no doubt wondering whether I was trying to prove her wrong. Then, after a long, contemplative pause, she nodded. “Only grew normal flowers…” She considered it for a moment, “I’m sure she said ‘flowers’ but I think she used the wrong word,” she said, obviously contemptuous of anybody who would do that.
“Flora, she meant,” I suggested as humbly as I could manage without laughing out loud. “The normal kinds of bacteria that grow in the region,” I added, to assuage her skeptically tight brow.
“But not yeasts,” Janice added to hammer home her point. “I’m very particular about cleaning myself, so there’s no way stuff like that could have crawled in.”
I tried not to react, and when the horror had receded from her face, I suggested I would like to see if I could resolve the issue for her, once and for all.
Another suspicious glance, a moment of closed-eyed silence, and then a nod. “But I want your nurse in with us,” she managed to whisper through gritted teeth and lips that looked as though they’d been sewn shut. I readily agreed; I was going to suggest it myself.
As it turned out, I was unable to find any evidence of a yeast infection when I looked at samples from the vagina under the microscope. Just some areas that appeared white, like a thin veneer on the skin near the vagina. She was so elated at the vindication and the wisdom of those online forums that she even agreed to let me do some cultures and a couple of biopsies.
A different Janice walked through the door a week later to discuss the results. Her face was relaxed, and so was the hair that now hung loosely and in curls to her shoulders. No more frayed blouse, no ankle length skirt –just jeans and a grey, baggy sweat shirt. Maybe it was the real her.
“Well, doc, what’s the news?”
“No yeast,” I answered, scanning the reports. “And no STIs,” I added with a grin, that was magnified by a chuckle on her part. “No cancer…”
She sighed loudly and a bit theatrically. “I didn’t come back here to discuss what I don’t have, doctor.” But she said it with a twinkle in her eyes. ‘At least we don’t have yeasts,’ they whispered to each other almost conspiratorially, as only eyes can do.
“The biopsies showed a skin condition called lichen sclerosus,” I explained. “It’s a thinning of the skin, probably caused by the immune system…”
“Not an infection?” She was immediately suspicious again.
I shook my head.
“So what’s the treatment?” Wariness once more surfaced on her face, hardening it into little wrinkles.
I smiled to diffuse the tension. “A steroid ointment you have to apply daily to the area for a few weeks. It turns off the immune response causing the skin problem.” I had to tread a bit carefully with this; to tell the truth I wasn’t sure this was the entire mechanism.
“Does it affect yeasts?” her face knotted up even further. “Because you have to be careful about that, you know.”
I raised an eyebrow as a form of silent question –one that I hoped would encourage her to expand on her concern.
“You know what we’re doing to bacteria..?” I wasn’t sure whether she wanted me to answer, but fortunately she resolved the question by answering it herself. “We use so many antibiotics we’re encouraging resistant germs: Superbugs!” She said the last word with such horror, it was as if she had just mentioned the Devil. I almost expected her to cross herself as a protection. “It’s all you read about nowadays. And we’re running out of effective antibiotics!” She stared at me with needle eyes, daring me to contradict the wisdom of her forums.
I scuffled around inside my head for the proper expression to wear. I finally settled on a serious, yet hopeful demeanor. Then I decided to draw her out. “Yeast are not bacteria, Janice… And anyway, they’re not your problem.”
“Doesn’t the immune system keep yeasts in check?”
“Well, in the vagina, lactobacilli help a lot…”
“What about people who get AIDS? Don’t they get overwhelming yeast infections?” She crossed her arms, certain she’d scored a point. “And don’t they have a turned-down immune system?” she added as a finishing coup.
I sat back in my chair, wondering where she was going with this. “And what is it you are concerned about, Janice?” I said when she seemed satisfied she had bested me.
“Superyeasts!” she answered defiantly. I could almost feel the italicization.
I had to chuckle; I couldn’t help myself. “You mean a yeast infection that is resistant to every known treatment?” I knew I was going to need to look that concept up later.
She nodded, satisfaction written across her body in bold letters. “Can you imagine a life lived with a permanent itch? Where scratching doesn’t work?” She had finally made her point –and, she hoped, maybe another convert. She knew she had to spread the word. Save the world from resistant stuff…
http://www.ncbi.nlm.nih.gov/pubmed/17906120 Candida drug resistance
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC105901/ Candida resistance in HIV