Even if the external evidence suggests a good treatment for your patient, he or she might have a number of unforeseen reasons for choosing or not choosing that treatment. Therefore, a teenager who consults you with acne, whose friend developed pigmentation of the gums whilst taking minocycline, might initially refuse that treatment option. This does not mean that, if that drug is deemed to be the best choice in those circumstances, the dermatologist does not then go on to explain how rare such an event really is in order to reach a joint decision with the patient. Another patient with acne might come back demanding treatment with isotretinoin simply because his or her friend at school had similar treatment with excellent long-term results and tolerable side-effects. Again, although such a declaration might influence the consultation, this does not automatically mean that the dermatologist will concede to such a request if he or she feels that the treatment is not in the patient's best interest (for example very mild disease or a history of several unplanned pregnancies). The point here is that application of the best external evidence requires a dialogue with the patient to explore their values and expectations.
Sometimes, patients prefer to use something that they perceive to be more "natural", for example evening primrose oil rather than synthetic topical corticosteroids for atopic eczema. Sometimes patients prefer to forgo pharmacological treatment and instead undertake various measures to manipulate their environment. Others just prefer to take a few pills and forget about it. Some like creams, others like ointments. Some people do not wish to be involved in lengthy discussions of treatment options if indeed they believe that their doctor is the best person to help them choose a treatment option. For example, a person with a basal cell carcinoma may be happy to be recommended surgical excision rather than debate the 10 or so treatment options available to treat such lesions.
These issues of personal perception, belief models, locus of control, and personal experience only reveal themselves at the follow up consultation with the patient. Although patients'
treatment choices may at times appear to be at odds with the external trial reports, patients are human beings who have their own set of preferences and values, and these need to be respected and understood. Like the first patient encounter, this area is where the art of healing and science of medicine meet.25 Both the doctor and their patient may indeed resort to various "games" in order to achieve each other's ulterior motives.26
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