Ms. Dickinson is a 56 year-old new patient presenting with severe scalp dermatitis and psoriasiform scaling, for which a tentative diagnosis of scalp psoriasis has been made. She reports trying several topical agents, each for a few days on six different occasions over a 3-month period, with inadequate control. The referring dermatologist, who called you prior to the patient visit, is concerned that her insufficient response to therapy has been a result of poor compliance. He notes that she typically resists his treatment recommendations, and on several occasions has made blanket statements indicating her distrust of medical professionals.

During the visit, Ms. Dickinson appears indifferent to your smiling, sits with her arms and legs crossed, and avoids direct eye contact when you address her. Toward the end of the visit, you say: “I would like to prescribe a medication that comes as a liquid to get rid of the flakey, red spots on your scalp. Would you be willing to try this out for 4 weeks and then come back to see me? Does this sound like a reasonable plan?” She responds, “I am not sure, Doctor. People have given me many medicines for my scalp condition, but none of them helped. My last dermatologist promised me many things. In the end, he gave up on me. So why should I trust you?”