Alan Rockoff

Probably like many who work with the public, I often get the chance to see how little sense people can make. Even so, last week was unusual.

On Tuesday, I saw Beulah who had not been into my office for 8 years. “I showed Dr. Prince this spot on my leg,” she said. “It's been there a month, and I'm worried about it.”

“Just a blocked follicle,” I told her. “Put some bacitracin on it, and it will be fine.”

Beulah sighed with relief. “I don't need another cancer,” she said. “I already have stomach cancer. Dr. Prince told me I couldn't have surgery or any other treatment, because I wouldn't make it through. But I'm 98 years old, and I guess we all have to go sometime. I don't have any family left. They're all gone.

“I've lost 30 pounds,” she said, still spry enough to hop off the exam table. “None of my clothes fit anymore. But it's awfully good to hear that I don't have to worry about that spot on my leg.”

That is a relief, I agreed.

The next morning, I greeted Iris warmly. “How are those grandchildren?” she asked, as she always does. “Do you have any new pictures?”

“I thought you were moving to Florida, Iris,” I said.

“It's been a tough year,” she said, “so I had to come back.” She went on to tell me how her husband had become jaundiced and succumbed in less than 3 months to cancer of the bile duct. “It's crazy, Doctor,” she said. “Both of his brothers had cancer, they had operations years ago, and they're fine. My husband was never sick a day in his life, never even had to take anything for a headache. And now he's gone.”

We talked about Iris's own problem, scleroderma, which somehow was not progressing at all. Her only skin complaint, easily disposed of, was mild hand eczema.

After some further pleasantries and picture showing, Iris took out a bag of skin care products. “I'm running low on these,” she said. “Is there any way I could get some while I'm here?”

Sure she could.

Then on Thursday, Sybil came by, a robust woman of 79 who wanted some pigmented lesions checked. As I looked her over, I asked about her family.

“My baby brother has Lewy bodies dementia,” she said. “He's not doing very well. He's in a nursing home now, because his family couldn't take care of him anymore. He still recognizes us a little, or seems to, when we come to visit. It's very painful to watch.”

Then Sybil brightened, pointing to the brown spots on the backs of her hands. Can we laser these off?” she asked. “I really hate them.”

Of course we can.

By week's end, I was really perplexed. How do people do that, I wondered? How can they go from the profound to the trivial with no acknowledgment, no apology, no, “I know this will sound frivolous after what I just told you?” How do they manage such a sudden and seamless register change—as though an opera singer stopped mid aria and launched into “Jingle Bells” without so much as a wink? But they do. I am just about gone; I have outlived everyone around, but what a relief that I don't have skin cancer. My husband just died a painful and senseless death, but I need those creams to help my skin look younger. My little brother is wasting away before my eyes, and how about those pesky age spots.

On reflection, such paradoxes may be more apparent than real. Unless we succumb to deep depression or utter despair, we want to go on living. This means setting aside gloomy thoughts, even if just for a while, and attending to all matters, profound or trivial, that people pay attention to until giving up altogether.

Since no one can make tragedy go away, I guess it's nice to be able to mitigate its impact just a little now and then.

But the end of last week left me shaking my head. I hope never to stop trying, but I doubt that I'll ever really understand people as long as I live.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, email Dr. Rockoff at our editorial offices at sknews@elsevier.com

Probably like many who work with the public, I often get the chance to see how little sense people can make. Even so, last week was unusual.

On Tuesday, I saw Beulah who had not been into my office for 8 years. “I showed Dr. Prince this spot on my leg,” she said. “It's been there a month, and I'm worried about it.”

“Just a blocked follicle,” I told her. “Put some bacitracin on it, and it will be fine.”

Beulah sighed with relief. “I don't need another cancer,” she said. “I already have stomach cancer. Dr. Prince told me I couldn't have surgery or any other treatment, because I wouldn't make it through. But I'm 98 years old, and I guess we all have to go sometime. I don't have any family left. They're all gone.

“I've lost 30 pounds,” she said, still spry enough to hop off the exam table. “None of my clothes fit anymore. But it's awfully good to hear that I don't have to worry about that spot on my leg.”

That is a relief, I agreed.

The next morning, I greeted Iris warmly. “How are those grandchildren?” she asked, as she always does. “Do you have any new pictures?”

“I thought you were moving to Florida, Iris,” I said.

“It's been a tough year,” she said, “so I had to come back.” She went on to tell me how her husband had become jaundiced and succumbed in less than 3 months to cancer of the bile duct. “It's crazy, Doctor,” she said. “Both of his brothers had cancer, they had operations years ago, and they're fine. My husband was never sick a day in his life, never even had to take anything for a headache. And now he's gone.”

We talked about Iris's own problem, scleroderma, which somehow was not progressing at all. Her only skin complaint, easily disposed of, was mild hand eczema.

After some further pleasantries and picture showing, Iris took out a bag of skin care products. “I'm running low on these,” she said. “Is there any way I could get some while I'm here?”

Sure she could.

Then on Thursday, Sybil came by, a robust woman of 79 who wanted some pigmented lesions checked. As I looked her over, I asked about her family.

“My baby brother has Lewy bodies dementia,” she said. “He's not doing very well. He's in a nursing home now, because his family couldn't take care of him anymore. He still recognizes us a little, or seems to, when we come to visit. It's very painful to watch.”

Then Sybil brightened, pointing to the brown spots on the backs of her hands. Can we laser these off?” she asked. “I really hate them.”

Of course we can.

By week's end, I was really perplexed. How do people do that, I wondered? How can they go from the profound to the trivial with no acknowledgment, no apology, no, “I know this will sound frivolous after what I just told you?” How do they manage such a sudden and seamless register change—as though an opera singer stopped mid aria and launched into “Jingle Bells” without so much as a wink? But they do. I am just about gone; I have outlived everyone around, but what a relief that I don't have skin cancer. My husband just died a painful and senseless death, but I need those creams to help my skin look younger. My little brother is wasting away before my eyes, and how about those pesky age spots.

On reflection, such paradoxes may be more apparent than real. Unless we succumb to deep depression or utter despair, we want to go on living. This means setting aside gloomy thoughts, even if just for a while, and attending to all matters, profound or trivial, that people pay attention to until giving up altogether.

Since no one can make tragedy go away, I guess it's nice to be able to mitigate its impact just a little now and then.

But the end of last week left me shaking my head. I hope never to stop trying, but I doubt that I'll ever really understand people as long as I live.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, email Dr. Rockoff at our editorial offices at sknews@elsevier.com

Probably like many who work with the public, I often get the chance to see how little sense people can make. Even so, last week was unusual.

On Tuesday, I saw Beulah who had not been into my office for 8 years. “I showed Dr. Prince this spot on my leg,” she said. “It's been there a month, and I'm worried about it.”

“Just a blocked follicle,” I told her. “Put some bacitracin on it, and it will be fine.”

Beulah sighed with relief. “I don't need another cancer,” she said. “I already have stomach cancer. Dr. Prince told me I couldn't have surgery or any other treatment, because I wouldn't make it through. But I'm 98 years old, and I guess we all have to go sometime. I don't have any family left. They're all gone.

“I've lost 30 pounds,” she said, still spry enough to hop off the exam table. “None of my clothes fit anymore. But it's awfully good to hear that I don't have to worry about that spot on my leg.”

That is a relief, I agreed.

The next morning, I greeted Iris warmly. “How are those grandchildren?” she asked, as she always does. “Do you have any new pictures?”

“I thought you were moving to Florida, Iris,” I said.

“It's been a tough year,” she said, “so I had to come back.” She went on to tell me how her husband had become jaundiced and succumbed in less than 3 months to cancer of the bile duct. “It's crazy, Doctor,” she said. “Both of his brothers had cancer, they had operations years ago, and they're fine. My husband was never sick a day in his life, never even had to take anything for a headache. And now he's gone.”

We talked about Iris's own problem, scleroderma, which somehow was not progressing at all. Her only skin complaint, easily disposed of, was mild hand eczema.

After some further pleasantries and picture showing, Iris took out a bag of skin care products. “I'm running low on these,” she said. “Is there any way I could get some while I'm here?”

Sure she could.

Then on Thursday, Sybil came by, a robust woman of 79 who wanted some pigmented lesions checked. As I looked her over, I asked about her family.

“My baby brother has Lewy bodies dementia,” she said. “He's not doing very well. He's in a nursing home now, because his family couldn't take care of him anymore. He still recognizes us a little, or seems to, when we come to visit. It's very painful to watch.”

Then Sybil brightened, pointing to the brown spots on the backs of her hands. Can we laser these off?” she asked. “I really hate them.”

Of course we can.

By week's end, I was really perplexed. How do people do that, I wondered? How can they go from the profound to the trivial with no acknowledgment, no apology, no, “I know this will sound frivolous after what I just told you?” How do they manage such a sudden and seamless register change—as though an opera singer stopped mid aria and launched into “Jingle Bells” without so much as a wink? But they do. I am just about gone; I have outlived everyone around, but what a relief that I don't have skin cancer. My husband just died a painful and senseless death, but I need those creams to help my skin look younger. My little brother is wasting away before my eyes, and how about those pesky age spots.

On reflection, such paradoxes may be more apparent than real. Unless we succumb to deep depression or utter despair, we want to go on living. This means setting aside gloomy thoughts, even if just for a while, and attending to all matters, profound or trivial, that people pay attention to until giving up altogether.

Since no one can make tragedy go away, I guess it's nice to be able to mitigate its impact just a little now and then.

But the end of last week left me shaking my head. I hope never to stop trying, but I doubt that I'll ever really understand people as long as I live.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, email Dr. Rockoff at our editorial offices at sknews@elsevier.com

Rosalie hadn't been by in 3 years. Her chief concern was a growth on her forearm. Then she pointed to a cholesterol deposit above her right eye. “I thought it might have been from crying,” she said. “My daughter died 14 months ago. She was 26.”

I expressed sympathy, and asked if her daughter had been ill. “It's a long story,” she said, “but the short of it is that she had a boyfriend who was not a good person. He stored a gun in her closet, and she didn't even know it was there. One night she came home after going out drinking with her girlfriends, other nurses from the hospital. She tripped in the closet, and the gun went off.

“She used to be your patient,” Rosalie said. “Maybe you remember—she got those crazy warts when she was in middle school.” I checked my records. Her daughter's last visit was in 1996, when she was 13.

In our offices, as elsewhere in our lives, people pass across our line of vision and disappear. We may find out what becomes of them, medically or otherwise, but more often we don't. Sometimes a chance encounter brings their image back into focus, but for the most part, once out of sight they stay out of mind.

This is true not just of patients like Rosalie's daughter who come a time or two for a minor complaint, but for those we get to know over a sustained period. All at once you realize that you haven't seen them lately, and perhaps never will.

Terry is so familiar that I was surprised to see she hadn't come for over a year. Now past 80, she looked a bit frailer but still reasonably hale. I recalled that Tim, her husband and inseparable companion, hadn't come along for her last couple of visits. He wasn't up to it, she'd explained. His mind was getting a little fuzzy. He sent his regards.

This time I asked Terry about him with some hesitation. Dementia, after all, goes in just one direction. “He's doing fairly well,” she said. “Lately when Tim sees women on the TV, he thinks they can see him, so he won't undress in the bedroom because he's embarrassed. I tell him, 'Timmy, why aren't you worried that the men in the TV can see me?' But he still won't get into his pajamas until I turn off the TV.

“During the day he's pretty content,” she went on. “He just sits there by his radio, all day long. He loves to listen to it and look out the window. He can sit there for hours.”

Terry's report jogged my memory of the way Tim looked when I saw him last, an affable gent with a wiry build and thinning brown hair. He always had a smile on his face, ready to help me reassure his wife, the worrier of the pair. At the end of each visit I would wish them good health and say I was looking forward to seeing them next year. Now that I won't be seeing him anymore, I'll have to picture the Tim in Terry's description, listening to his murmuring radio and gazing out the window as he subsides into his own deepening twilight.

Of course, it's not only patients who are lost to follow-up. People come to the office and tell me they had a physical or biopsy as recently as 2 or 3 years ago but cannot for the life of them remember which doctor they saw. It's not even unusual for someone to come back to me after an absence of a decade or two and express disbelief that they'd ever been here, since neither the office nor its proprietor rang a bell.

When I was starting out in practice, an older colleague told me that once he announced his retirement, his mailbox filled and his phone rang off the hook with messages from anguished patients declaring that they simply would not be able to get along without him. “They did manage, though,” he said. “In most cases it took only a couple of weeks.”

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at sknews@elsevier.com

Rosalie hadn't been by in 3 years. Her chief concern was a growth on her forearm. Then she pointed to a cholesterol deposit above her right eye. “I thought it might have been from crying,” she said. “My daughter died 14 months ago. She was 26.”

I expressed sympathy, and asked if her daughter had been ill. “It's a long story,” she said, “but the short of it is that she had a boyfriend who was not a good person. He stored a gun in her closet, and she didn't even know it was there. One night she came home after going out drinking with her girlfriends, other nurses from the hospital. She tripped in the closet, and the gun went off.

“She used to be your patient,” Rosalie said. “Maybe you remember—she got those crazy warts when she was in middle school.” I checked my records. Her daughter's last visit was in 1996, when she was 13.

In our offices, as elsewhere in our lives, people pass across our line of vision and disappear. We may find out what becomes of them, medically or otherwise, but more often we don't. Sometimes a chance encounter brings their image back into focus, but for the most part, once out of sight they stay out of mind.

This is true not just of patients like Rosalie's daughter who come a time or two for a minor complaint, but for those we get to know over a sustained period. All at once you realize that you haven't seen them lately, and perhaps never will.

Terry is so familiar that I was surprised to see she hadn't come for over a year. Now past 80, she looked a bit frailer but still reasonably hale. I recalled that Tim, her husband and inseparable companion, hadn't come along for her last couple of visits. He wasn't up to it, she'd explained. His mind was getting a little fuzzy. He sent his regards.

This time I asked Terry about him with some hesitation. Dementia, after all, goes in just one direction. “He's doing fairly well,” she said. “Lately when Tim sees women on the TV, he thinks they can see him, so he won't undress in the bedroom because he's embarrassed. I tell him, 'Timmy, why aren't you worried that the men in the TV can see me?' But he still won't get into his pajamas until I turn off the TV.

“During the day he's pretty content,” she went on. “He just sits there by his radio, all day long. He loves to listen to it and look out the window. He can sit there for hours.”

Terry's report jogged my memory of the way Tim looked when I saw him last, an affable gent with a wiry build and thinning brown hair. He always had a smile on his face, ready to help me reassure his wife, the worrier of the pair. At the end of each visit I would wish them good health and say I was looking forward to seeing them next year. Now that I won't be seeing him anymore, I'll have to picture the Tim in Terry's description, listening to his murmuring radio and gazing out the window as he subsides into his own deepening twilight.

Of course, it's not only patients who are lost to follow-up. People come to the office and tell me they had a physical or biopsy as recently as 2 or 3 years ago but cannot for the life of them remember which doctor they saw. It's not even unusual for someone to come back to me after an absence of a decade or two and express disbelief that they'd ever been here, since neither the office nor its proprietor rang a bell.

When I was starting out in practice, an older colleague told me that once he announced his retirement, his mailbox filled and his phone rang off the hook with messages from anguished patients declaring that they simply would not be able to get along without him. “They did manage, though,” he said. “In most cases it took only a couple of weeks.”

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at sknews@elsevier.com

Rosalie hadn't been by in 3 years. Her chief concern was a growth on her forearm. Then she pointed to a cholesterol deposit above her right eye. “I thought it might have been from crying,” she said. “My daughter died 14 months ago. She was 26.”

I expressed sympathy, and asked if her daughter had been ill. “It's a long story,” she said, “but the short of it is that she had a boyfriend who was not a good person. He stored a gun in her closet, and she didn't even know it was there. One night she came home after going out drinking with her girlfriends, other nurses from the hospital. She tripped in the closet, and the gun went off.

“She used to be your patient,” Rosalie said. “Maybe you remember—she got those crazy warts when she was in middle school.” I checked my records. Her daughter's last visit was in 1996, when she was 13.

In our offices, as elsewhere in our lives, people pass across our line of vision and disappear. We may find out what becomes of them, medically or otherwise, but more often we don't. Sometimes a chance encounter brings their image back into focus, but for the most part, once out of sight they stay out of mind.

This is true not just of patients like Rosalie's daughter who come a time or two for a minor complaint, but for those we get to know over a sustained period. All at once you realize that you haven't seen them lately, and perhaps never will.

Terry is so familiar that I was surprised to see she hadn't come for over a year. Now past 80, she looked a bit frailer but still reasonably hale. I recalled that Tim, her husband and inseparable companion, hadn't come along for her last couple of visits. He wasn't up to it, she'd explained. His mind was getting a little fuzzy. He sent his regards.

This time I asked Terry about him with some hesitation. Dementia, after all, goes in just one direction. “He's doing fairly well,” she said. “Lately when Tim sees women on the TV, he thinks they can see him, so he won't undress in the bedroom because he's embarrassed. I tell him, 'Timmy, why aren't you worried that the men in the TV can see me?' But he still won't get into his pajamas until I turn off the TV.

“During the day he's pretty content,” she went on. “He just sits there by his radio, all day long. He loves to listen to it and look out the window. He can sit there for hours.”

Terry's report jogged my memory of the way Tim looked when I saw him last, an affable gent with a wiry build and thinning brown hair. He always had a smile on his face, ready to help me reassure his wife, the worrier of the pair. At the end of each visit I would wish them good health and say I was looking forward to seeing them next year. Now that I won't be seeing him anymore, I'll have to picture the Tim in Terry's description, listening to his murmuring radio and gazing out the window as he subsides into his own deepening twilight.

Of course, it's not only patients who are lost to follow-up. People come to the office and tell me they had a physical or biopsy as recently as 2 or 3 years ago but cannot for the life of them remember which doctor they saw. It's not even unusual for someone to come back to me after an absence of a decade or two and express disbelief that they'd ever been here, since neither the office nor its proprietor rang a bell.

When I was starting out in practice, an older colleague told me that once he announced his retirement, his mailbox filled and his phone rang off the hook with messages from anguished patients declaring that they simply would not be able to get along without him. “They did manage, though,” he said. “In most cases it took only a couple of weeks.”

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at sknews@elsevier.com

I'm old enough to remember the actor Robert Young in “Father Knows Best.” Because his later hit TV series “Marcus Welby, M.D.” aired when I was in medical school and residency, I never saw a single episode, but his image as the kindly general practitioner who knew everybody in town seeped into my consciousness.

I am not a GP in a small town but a specialist in a big, anonymous urban agglomeration, where you don't expect to meet people you know when you walk down the street. Patients come from all directions (well, not the east—they'd have to swim). Some live nearby; others come from towns and travel in circles at some distance. Still, after 30 years, these circles sometimes intersect in unexpected ways, producing intimations of small-town, Welby warmth that can frankly be rather nice.

There was the time, for instance, when I was writing up a note one evening at a rest home nursing station, when the night nurse, who didn't look at all familiar, said, “I brought my son Ted to see you when he had warts as a kid.”

“How old is Ted now?” I asked.

“Thirty-six,” she said. “He has two kids and lives in Chicago. He still remembers how you used to pour the liquid nitrogen on the floor.”

You never know what leaves an impression on kids, including your own.

Two recent incidents illustrate what can happen when you hang around long enough. Shortly before I left for a week off last spring, my associate was called for jury duty on a Monday, the first day I was to be away.

Having already rescheduled once, she had no choice but to go to the courthouse in downtown Boston. We decided not to cancel patients for Tuesday and beyond until she found out whether she would be impaneled on a jury or released the same day. When the judge asked if anyone would find it difficult to stay for a trial, she came forward and told him that because I was away, she was the only one available to see patients.

The judge looked at her forms and frowned. “Dermatology, eh?” he said. “Not many emergencies there.”

He seemed disinclined to let her off. Then he looked further and said: “Full disclosure. I'm one of Dr. Rockoff's patients. Have a good day.”

When I saw the good judge some weeks later, I expressed surprise that he was presiding in a Boston courthouse, since his usual bailiwick is about 50 miles southeast. It turns out that he just happened to be assigned to Boston that day. Good thing, too.

A similar incident happened a few weeks ago when I exited a highway a few miles from my office onto a street with three lanes of traffic. I stayed in the right lane, which was clear. Several hundred yards further on, I learned why it was so clear: A sign read, “Right Lane Must Turn Right.” The famously aggressive Boston drivers in the jammed lane to my left seemed unlikely to let me in, leaving me with the prospect of turning onto an unfamiliar street that headed nowhere, certainly not where I wanted to go.

I, therefore, ignored the sign and drove straight through—into a police trap. An officer motioned for me to pull over behind the line of perpetrators already apprehended. As he asked for my license and registration, I fumed. “Relax, sir,” he said, “You're just getting a warning.” He walked to his cruiser to examine my documents.

A few minutes later a different officer came over, smiling broadly. “I really need to make an appointment,” he said. “I'm late for my annual. Drive safe,” he said, handing me my papers.

The truth is, I didn't recognize him, but I'll be sure to do so the next time he comes in.

I'm not suggesting being pleasant or helpful for the purpose of getting off jury duty or avoiding tickets. There are better reasons for trying to be competent, and besides, the odds against a practical payoff are too long.

Still, it is nice when, after casting bread upon the waters for a decade or three, some of it unexpectedly—and pleasantly—comes back.

Move over, Marcus.

I'm old enough to remember the actor Robert Young in “Father Knows Best.” Because his later hit TV series “Marcus Welby, M.D.” aired when I was in medical school and residency, I never saw a single episode, but his image as the kindly general practitioner who knew everybody in town seeped into my consciousness.

I am not a GP in a small town but a specialist in a big, anonymous urban agglomeration, where you don't expect to meet people you know when you walk down the street. Patients come from all directions (well, not the east—they'd have to swim). Some live nearby; others come from towns and travel in circles at some distance. Still, after 30 years, these circles sometimes intersect in unexpected ways, producing intimations of small-town, Welby warmth that can frankly be rather nice.

There was the time, for instance, when I was writing up a note one evening at a rest home nursing station, when the night nurse, who didn't look at all familiar, said, “I brought my son Ted to see you when he had warts as a kid.”

“How old is Ted now?” I asked.

“Thirty-six,” she said. “He has two kids and lives in Chicago. He still remembers how you used to pour the liquid nitrogen on the floor.”

You never know what leaves an impression on kids, including your own.

Two recent incidents illustrate what can happen when you hang around long enough. Shortly before I left for a week off last spring, my associate was called for jury duty on a Monday, the first day I was to be away.

Having already rescheduled once, she had no choice but to go to the courthouse in downtown Boston. We decided not to cancel patients for Tuesday and beyond until she found out whether she would be impaneled on a jury or released the same day. When the judge asked if anyone would find it difficult to stay for a trial, she came forward and told him that because I was away, she was the only one available to see patients.

The judge looked at her forms and frowned. “Dermatology, eh?” he said. “Not many emergencies there.”

He seemed disinclined to let her off. Then he looked further and said: “Full disclosure. I'm one of Dr. Rockoff's patients. Have a good day.”

When I saw the good judge some weeks later, I expressed surprise that he was presiding in a Boston courthouse, since his usual bailiwick is about 50 miles southeast. It turns out that he just happened to be assigned to Boston that day. Good thing, too.

A similar incident happened a few weeks ago when I exited a highway a few miles from my office onto a street with three lanes of traffic. I stayed in the right lane, which was clear. Several hundred yards further on, I learned why it was so clear: A sign read, “Right Lane Must Turn Right.” The famously aggressive Boston drivers in the jammed lane to my left seemed unlikely to let me in, leaving me with the prospect of turning onto an unfamiliar street that headed nowhere, certainly not where I wanted to go.

I, therefore, ignored the sign and drove straight through—into a police trap. An officer motioned for me to pull over behind the line of perpetrators already apprehended. As he asked for my license and registration, I fumed. “Relax, sir,” he said, “You're just getting a warning.” He walked to his cruiser to examine my documents.

A few minutes later a different officer came over, smiling broadly. “I really need to make an appointment,” he said. “I'm late for my annual. Drive safe,” he said, handing me my papers.

The truth is, I didn't recognize him, but I'll be sure to do so the next time he comes in.

I'm not suggesting being pleasant or helpful for the purpose of getting off jury duty or avoiding tickets. There are better reasons for trying to be competent, and besides, the odds against a practical payoff are too long.

Still, it is nice when, after casting bread upon the waters for a decade or three, some of it unexpectedly—and pleasantly—comes back.

Move over, Marcus.

I'm old enough to remember the actor Robert Young in “Father Knows Best.” Because his later hit TV series “Marcus Welby, M.D.” aired when I was in medical school and residency, I never saw a single episode, but his image as the kindly general practitioner who knew everybody in town seeped into my consciousness.

I am not a GP in a small town but a specialist in a big, anonymous urban agglomeration, where you don't expect to meet people you know when you walk down the street. Patients come from all directions (well, not the east—they'd have to swim). Some live nearby; others come from towns and travel in circles at some distance. Still, after 30 years, these circles sometimes intersect in unexpected ways, producing intimations of small-town, Welby warmth that can frankly be rather nice.

There was the time, for instance, when I was writing up a note one evening at a rest home nursing station, when the night nurse, who didn't look at all familiar, said, “I brought my son Ted to see you when he had warts as a kid.”

“How old is Ted now?” I asked.

“Thirty-six,” she said. “He has two kids and lives in Chicago. He still remembers how you used to pour the liquid nitrogen on the floor.”

You never know what leaves an impression on kids, including your own.

Two recent incidents illustrate what can happen when you hang around long enough. Shortly before I left for a week off last spring, my associate was called for jury duty on a Monday, the first day I was to be away.

Having already rescheduled once, she had no choice but to go to the courthouse in downtown Boston. We decided not to cancel patients for Tuesday and beyond until she found out whether she would be impaneled on a jury or released the same day. When the judge asked if anyone would find it difficult to stay for a trial, she came forward and told him that because I was away, she was the only one available to see patients.

The judge looked at her forms and frowned. “Dermatology, eh?” he said. “Not many emergencies there.”

He seemed disinclined to let her off. Then he looked further and said: “Full disclosure. I'm one of Dr. Rockoff's patients. Have a good day.”

When I saw the good judge some weeks later, I expressed surprise that he was presiding in a Boston courthouse, since his usual bailiwick is about 50 miles southeast. It turns out that he just happened to be assigned to Boston that day. Good thing, too.

A similar incident happened a few weeks ago when I exited a highway a few miles from my office onto a street with three lanes of traffic. I stayed in the right lane, which was clear. Several hundred yards further on, I learned why it was so clear: A sign read, “Right Lane Must Turn Right.” The famously aggressive Boston drivers in the jammed lane to my left seemed unlikely to let me in, leaving me with the prospect of turning onto an unfamiliar street that headed nowhere, certainly not where I wanted to go.

I, therefore, ignored the sign and drove straight through—into a police trap. An officer motioned for me to pull over behind the line of perpetrators already apprehended. As he asked for my license and registration, I fumed. “Relax, sir,” he said, “You're just getting a warning.” He walked to his cruiser to examine my documents.

A few minutes later a different officer came over, smiling broadly. “I really need to make an appointment,” he said. “I'm late for my annual. Drive safe,” he said, handing me my papers.

The truth is, I didn't recognize him, but I'll be sure to do so the next time he comes in.

I'm not suggesting being pleasant or helpful for the purpose of getting off jury duty or avoiding tickets. There are better reasons for trying to be competent, and besides, the odds against a practical payoff are too long.

Still, it is nice when, after casting bread upon the waters for a decade or three, some of it unexpectedly—and pleasantly—comes back.

Move over, Marcus.

There was a comic when I was a kid called “The Strange World of Mr. Mum.” Each strip featured an impassive gent in a small fedora who looked on, mum, at the odd things that always seemed to be going on as he passed by, like two masked crooks robbing each other at the same time.

Now and then things happen in my office that make me feel like Mr. Mum. I share them here without comment.

Tim, a 30ish architect with sandy hair, had petechiae around his eyes. I asked him whether he had been coughing very hard or straining at stool. Negative.

I mentally ran through other possibilities. Let's see, too old to be a baby born with a cord around his neck. … Tim broke into my reverie.

“Doctor, could walking on my hands across the office have anything to do with this?”

“Well, yes, Tim. Would I be out of line to ask why you walk across your office on your hands?”

“Oh, I just do it sometimes.”

Lynn flashed me a conspiratorial look. “Could your student leave the room?”

“Of course.” I shooed the kid out, wondering what private matter she had to discuss.

“I'm thinking of getting plastic surgery,” she said. “Tell me, who did your face?”

“What?!”

“No, really, just between us, I won't tell anybody. Who did your face?”

I managed to regain enough composure to say that I guessed I was flattered, but nobody did my face. She looked skeptical.

I didn't share this interchange with my student, who wouldn't have believed it anyway.

At a local medical conference, the guest speaker was giving us a heads-up on ICD-10. “It's going to be a lot more detailed than ICD-9,” she explained, adding that ICD-10 is slated to become mandatory in October 2013. (I heard some murmurs that October 2013 might be a good date to retire.)

The speaker flashed several examples of new ICD-10 codes on the screen. “For instance,” she said, “this is the code for a benign lesion of the left eyelid. And this [next slide] is the code for a benign lesion of the right eyelid.”

A doctor raised his hand. “What difference does it make which lid it's on?” he asked.

Some people just don't get it.

My heart sank when I entered the exam room and saw a young woman with grotesquely enlarged, hollowed-out earlobes that literally hung to her shoulders. What could she possibly want me to do with them?

Sue was quite pleasant. “See, this is how I make them bigger,” she said. “I make a cut at the top, and then put in a larger and larger coin to make the hole bigger until the skin heals around it. Now the earlobes are as big as I want them.” Well, yes.

“But here's my problem.” Sue pointed to a slight protrusion of tissue at the cavity's upper pole, at 12 o'clock. In other words, her problem was not the huge hole—the hole is what she wanted—but the scar at the top that impinged on the cavity and marred its perfection.

“In that case,” I said, “I can help you. I'll inject some cortisone into the bump and flatten it.”

“Fantastic!” she exclaimed. I gave her the shot and asked what her career plans were.

“Social work,” she explained.

Bob, in for a skin check, had a healing scab on his forehead. “Looks like you ran into a pipe and didn't duck fast enough,” I suggested.

“Not exactly,” said Bob. “I was making squid and shrimp pasta in the microwave. When all the pieces got nice and plump, I decided to test whether they were done, so I stuck a fork into one of the squid, and it exploded. Guess I was lucky it didn't get my eye.”

Microwave-induced exploding cats are said to be urban legends, but now you know, gentle readers, that exploding squid have been sighted. So don't forget to ask about them when you take your histories, as well as about whether your patients walk on their hands across their offices (or stand on their heads doing yoga).

I'll take my fedora off, for now.

There was a comic when I was a kid called “The Strange World of Mr. Mum.” Each strip featured an impassive gent in a small fedora who looked on, mum, at the odd things that always seemed to be going on as he passed by, like two masked crooks robbing each other at the same time.

Now and then things happen in my office that make me feel like Mr. Mum. I share them here without comment.

Tim, a 30ish architect with sandy hair, had petechiae around his eyes. I asked him whether he had been coughing very hard or straining at stool. Negative.

I mentally ran through other possibilities. Let's see, too old to be a baby born with a cord around his neck. … Tim broke into my reverie.

“Doctor, could walking on my hands across the office have anything to do with this?”

“Well, yes, Tim. Would I be out of line to ask why you walk across your office on your hands?”

“Oh, I just do it sometimes.”

Lynn flashed me a conspiratorial look. “Could your student leave the room?”

“Of course.” I shooed the kid out, wondering what private matter she had to discuss.

“I'm thinking of getting plastic surgery,” she said. “Tell me, who did your face?”

“What?!”

“No, really, just between us, I won't tell anybody. Who did your face?”

I managed to regain enough composure to say that I guessed I was flattered, but nobody did my face. She looked skeptical.

I didn't share this interchange with my student, who wouldn't have believed it anyway.

At a local medical conference, the guest speaker was giving us a heads-up on ICD-10. “It's going to be a lot more detailed than ICD-9,” she explained, adding that ICD-10 is slated to become mandatory in October 2013. (I heard some murmurs that October 2013 might be a good date to retire.)

The speaker flashed several examples of new ICD-10 codes on the screen. “For instance,” she said, “this is the code for a benign lesion of the left eyelid. And this [next slide] is the code for a benign lesion of the right eyelid.”

A doctor raised his hand. “What difference does it make which lid it's on?” he asked.

Some people just don't get it.

My heart sank when I entered the exam room and saw a young woman with grotesquely enlarged, hollowed-out earlobes that literally hung to her shoulders. What could she possibly want me to do with them?

Sue was quite pleasant. “See, this is how I make them bigger,” she said. “I make a cut at the top, and then put in a larger and larger coin to make the hole bigger until the skin heals around it. Now the earlobes are as big as I want them.” Well, yes.

“But here's my problem.” Sue pointed to a slight protrusion of tissue at the cavity's upper pole, at 12 o'clock. In other words, her problem was not the huge hole—the hole is what she wanted—but the scar at the top that impinged on the cavity and marred its perfection.

“In that case,” I said, “I can help you. I'll inject some cortisone into the bump and flatten it.”

“Fantastic!” she exclaimed. I gave her the shot and asked what her career plans were.

“Social work,” she explained.

Bob, in for a skin check, had a healing scab on his forehead. “Looks like you ran into a pipe and didn't duck fast enough,” I suggested.

“Not exactly,” said Bob. “I was making squid and shrimp pasta in the microwave. When all the pieces got nice and plump, I decided to test whether they were done, so I stuck a fork into one of the squid, and it exploded. Guess I was lucky it didn't get my eye.”

Microwave-induced exploding cats are said to be urban legends, but now you know, gentle readers, that exploding squid have been sighted. So don't forget to ask about them when you take your histories, as well as about whether your patients walk on their hands across their offices (or stand on their heads doing yoga).

I'll take my fedora off, for now.

There was a comic when I was a kid called “The Strange World of Mr. Mum.” Each strip featured an impassive gent in a small fedora who looked on, mum, at the odd things that always seemed to be going on as he passed by, like two masked crooks robbing each other at the same time.

Now and then things happen in my office that make me feel like Mr. Mum. I share them here without comment.

Tim, a 30ish architect with sandy hair, had petechiae around his eyes. I asked him whether he had been coughing very hard or straining at stool. Negative.

I mentally ran through other possibilities. Let's see, too old to be a baby born with a cord around his neck. … Tim broke into my reverie.

“Doctor, could walking on my hands across the office have anything to do with this?”

“Well, yes, Tim. Would I be out of line to ask why you walk across your office on your hands?”

“Oh, I just do it sometimes.”

Lynn flashed me a conspiratorial look. “Could your student leave the room?”

“Of course.” I shooed the kid out, wondering what private matter she had to discuss.

“I'm thinking of getting plastic surgery,” she said. “Tell me, who did your face?”

“What?!”

“No, really, just between us, I won't tell anybody. Who did your face?”

I managed to regain enough composure to say that I guessed I was flattered, but nobody did my face. She looked skeptical.

I didn't share this interchange with my student, who wouldn't have believed it anyway.

At a local medical conference, the guest speaker was giving us a heads-up on ICD-10. “It's going to be a lot more detailed than ICD-9,” she explained, adding that ICD-10 is slated to become mandatory in October 2013. (I heard some murmurs that October 2013 might be a good date to retire.)

The speaker flashed several examples of new ICD-10 codes on the screen. “For instance,” she said, “this is the code for a benign lesion of the left eyelid. And this [next slide] is the code for a benign lesion of the right eyelid.”

A doctor raised his hand. “What difference does it make which lid it's on?” he asked.

Some people just don't get it.

My heart sank when I entered the exam room and saw a young woman with grotesquely enlarged, hollowed-out earlobes that literally hung to her shoulders. What could she possibly want me to do with them?

Sue was quite pleasant. “See, this is how I make them bigger,” she said. “I make a cut at the top, and then put in a larger and larger coin to make the hole bigger until the skin heals around it. Now the earlobes are as big as I want them.” Well, yes.

“But here's my problem.” Sue pointed to a slight protrusion of tissue at the cavity's upper pole, at 12 o'clock. In other words, her problem was not the huge hole—the hole is what she wanted—but the scar at the top that impinged on the cavity and marred its perfection.

“In that case,” I said, “I can help you. I'll inject some cortisone into the bump and flatten it.”

“Fantastic!” she exclaimed. I gave her the shot and asked what her career plans were.

“Social work,” she explained.

Bob, in for a skin check, had a healing scab on his forehead. “Looks like you ran into a pipe and didn't duck fast enough,” I suggested.

“Not exactly,” said Bob. “I was making squid and shrimp pasta in the microwave. When all the pieces got nice and plump, I decided to test whether they were done, so I stuck a fork into one of the squid, and it exploded. Guess I was lucky it didn't get my eye.”

Microwave-induced exploding cats are said to be urban legends, but now you know, gentle readers, that exploding squid have been sighted. So don't forget to ask about them when you take your histories, as well as about whether your patients walk on their hands across their offices (or stand on their heads doing yoga).

I'll take my fedora off, for now.

It has been a tough week. If my staff ever decides to change careers, they should be well trained for work in a complaints department.

First there was Doris, a 50-something-year-old woman who's been my patient for years. Her rosacea flared up, so I wrote a prescription for doxycycline to help treat her face for her daughter's upcoming wedding. The next day I got a request that I fax another prescription to a mail-order pharmacy somewhere in Outer Darkness where rent and wages are low. Two days later the mail-order droid requested a clarification: hyclate or monohydrate? (Why does no other pharmacy ever ask me this?) I faxed back my answer.

Now here was Doris berating my secretary loudly and at length because the mail-order droid was still preparing her order. She demanded that we pay for overnight shipping to compensate for our sloppy incompetence. For good measure, she canceled her next appointment.

Asking us to pay for shipping was a new one. (A patient once did demand that I pay for dry-cleaning a dress when bacitracin from a dressing got on it.) I called Doris back, and left a polite voice mail message suggesting that she direct complaints of this nature to the mail-order pharmacy whose procedures were perhaps more pertinent than ours to her dilemma.

Later the same day Alfred came in, a slovenly and truculent man in his early 70s. His real concern was that we take off his facial keratoses. (You really can't tell a cosmetic patient by appearance.)

Alfred had a slightly raised patch on his right cheek that seemed at an earlier visit to be a vascular macule but had now developed a bit of texture. I explained that laser surgery would not work and suggested light curettage both to remove the spot and test it to rule out skin cancer.

Alfred would agree to this only if I guaranteed—in writing—that there would be no mark left afterward. I explained that I couldn't offer such a guarantee and why I felt it would be best to test the lesion (adding that leaving it there would guarantee that he would still have a spot). “Oh, so now we're just speculating,” he growled and walked out.

And you have a nice day too, sir.

The next day was even better. My PA, Megan, who has a soft manner and infinite patience, told me she had just endured a telephone tirade from a woman whose 21-year-old daughter had tinea of her toenails. We had actually diagnosed this 7 years earlier, offered the patient treatment with oral terbinafine, and asked her mother to arrange for liver function testing as a possible prelude to treatment.

They never got the testing done, and the patient had been back several times over the years for other issues without ever raising the fungal concern. Megan heard our mother patiently, spoke soothingly, and talked about treating with terbinafine when her daughter returned from school in May.

“In my family we don't use generics,” came her frosty reply.

I called Mom back. (At the time she was in Florida with her daughter, on spring break.) I explained that generic drugs can indeed be okay. (“I had a bad experience with one,” she reported.)

I told her that we could certainly start antifungal treatment after this semester, if her daughter wanted us to. And so on. She sounded mollified.

The question of course is: Why now? After having fungal toenails for 7 years, why did her daughter suddenly find it urgent to treat them? What about all those visits in between, spanning most of her adolescence?

People just get cranky, I suppose, and it was our misfortune to encounter three in a row. I guess I ought to make allowances for matrons aflutter in the run up to their daughter's wedding, or for gents who care deeply about their appearance, or for parents of excitable young ladies with acutely intolerable toenails, all of whom have decided to relieve their inner tension by beating up on me or my staff in full-throated arias of crankiness.

Only I'm feeling cranky myself just now, so I'm not in the mood for making allowances. You'll understand, won't you?

You won't? Too bad.

It has been a tough week. If my staff ever decides to change careers, they should be well trained for work in a complaints department.

First there was Doris, a 50-something-year-old woman who's been my patient for years. Her rosacea flared up, so I wrote a prescription for doxycycline to help treat her face for her daughter's upcoming wedding. The next day I got a request that I fax another prescription to a mail-order pharmacy somewhere in Outer Darkness where rent and wages are low. Two days later the mail-order droid requested a clarification: hyclate or monohydrate? (Why does no other pharmacy ever ask me this?) I faxed back my answer.

Now here was Doris berating my secretary loudly and at length because the mail-order droid was still preparing her order. She demanded that we pay for overnight shipping to compensate for our sloppy incompetence. For good measure, she canceled her next appointment.

Asking us to pay for shipping was a new one. (A patient once did demand that I pay for dry-cleaning a dress when bacitracin from a dressing got on it.) I called Doris back, and left a polite voice mail message suggesting that she direct complaints of this nature to the mail-order pharmacy whose procedures were perhaps more pertinent than ours to her dilemma.

Later the same day Alfred came in, a slovenly and truculent man in his early 70s. His real concern was that we take off his facial keratoses. (You really can't tell a cosmetic patient by appearance.)

Alfred had a slightly raised patch on his right cheek that seemed at an earlier visit to be a vascular macule but had now developed a bit of texture. I explained that laser surgery would not work and suggested light curettage both to remove the spot and test it to rule out skin cancer.

Alfred would agree to this only if I guaranteed—in writing—that there would be no mark left afterward. I explained that I couldn't offer such a guarantee and why I felt it would be best to test the lesion (adding that leaving it there would guarantee that he would still have a spot). “Oh, so now we're just speculating,” he growled and walked out.

And you have a nice day too, sir.

The next day was even better. My PA, Megan, who has a soft manner and infinite patience, told me she had just endured a telephone tirade from a woman whose 21-year-old daughter had tinea of her toenails. We had actually diagnosed this 7 years earlier, offered the patient treatment with oral terbinafine, and asked her mother to arrange for liver function testing as a possible prelude to treatment.

They never got the testing done, and the patient had been back several times over the years for other issues without ever raising the fungal concern. Megan heard our mother patiently, spoke soothingly, and talked about treating with terbinafine when her daughter returned from school in May.

“In my family we don't use generics,” came her frosty reply.

I called Mom back. (At the time she was in Florida with her daughter, on spring break.) I explained that generic drugs can indeed be okay. (“I had a bad experience with one,” she reported.)

I told her that we could certainly start antifungal treatment after this semester, if her daughter wanted us to. And so on. She sounded mollified.

The question of course is: Why now? After having fungal toenails for 7 years, why did her daughter suddenly find it urgent to treat them? What about all those visits in between, spanning most of her adolescence?

People just get cranky, I suppose, and it was our misfortune to encounter three in a row. I guess I ought to make allowances for matrons aflutter in the run up to their daughter's wedding, or for gents who care deeply about their appearance, or for parents of excitable young ladies with acutely intolerable toenails, all of whom have decided to relieve their inner tension by beating up on me or my staff in full-throated arias of crankiness.

Only I'm feeling cranky myself just now, so I'm not in the mood for making allowances. You'll understand, won't you?

You won't? Too bad.

It has been a tough week. If my staff ever decides to change careers, they should be well trained for work in a complaints department.

First there was Doris, a 50-something-year-old woman who's been my patient for years. Her rosacea flared up, so I wrote a prescription for doxycycline to help treat her face for her daughter's upcoming wedding. The next day I got a request that I fax another prescription to a mail-order pharmacy somewhere in Outer Darkness where rent and wages are low. Two days later the mail-order droid requested a clarification: hyclate or monohydrate? (Why does no other pharmacy ever ask me this?) I faxed back my answer.

Now here was Doris berating my secretary loudly and at length because the mail-order droid was still preparing her order. She demanded that we pay for overnight shipping to compensate for our sloppy incompetence. For good measure, she canceled her next appointment.

Asking us to pay for shipping was a new one. (A patient once did demand that I pay for dry-cleaning a dress when bacitracin from a dressing got on it.) I called Doris back, and left a polite voice mail message suggesting that she direct complaints of this nature to the mail-order pharmacy whose procedures were perhaps more pertinent than ours to her dilemma.

Later the same day Alfred came in, a slovenly and truculent man in his early 70s. His real concern was that we take off his facial keratoses. (You really can't tell a cosmetic patient by appearance.)

Alfred had a slightly raised patch on his right cheek that seemed at an earlier visit to be a vascular macule but had now developed a bit of texture. I explained that laser surgery would not work and suggested light curettage both to remove the spot and test it to rule out skin cancer.

Alfred would agree to this only if I guaranteed—in writing—that there would be no mark left afterward. I explained that I couldn't offer such a guarantee and why I felt it would be best to test the lesion (adding that leaving it there would guarantee that he would still have a spot). “Oh, so now we're just speculating,” he growled and walked out.

And you have a nice day too, sir.

The next day was even better. My PA, Megan, who has a soft manner and infinite patience, told me she had just endured a telephone tirade from a woman whose 21-year-old daughter had tinea of her toenails. We had actually diagnosed this 7 years earlier, offered the patient treatment with oral terbinafine, and asked her mother to arrange for liver function testing as a possible prelude to treatment.

They never got the testing done, and the patient had been back several times over the years for other issues without ever raising the fungal concern. Megan heard our mother patiently, spoke soothingly, and talked about treating with terbinafine when her daughter returned from school in May.

“In my family we don't use generics,” came her frosty reply.

I called Mom back. (At the time she was in Florida with her daughter, on spring break.) I explained that generic drugs can indeed be okay. (“I had a bad experience with one,” she reported.)

I told her that we could certainly start antifungal treatment after this semester, if her daughter wanted us to. And so on. She sounded mollified.

The question of course is: Why now? After having fungal toenails for 7 years, why did her daughter suddenly find it urgent to treat them? What about all those visits in between, spanning most of her adolescence?

People just get cranky, I suppose, and it was our misfortune to encounter three in a row. I guess I ought to make allowances for matrons aflutter in the run up to their daughter's wedding, or for gents who care deeply about their appearance, or for parents of excitable young ladies with acutely intolerable toenails, all of whom have decided to relieve their inner tension by beating up on me or my staff in full-throated arias of crankiness.

Only I'm feeling cranky myself just now, so I'm not in the mood for making allowances. You'll understand, won't you?

You won't? Too bad.

Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.

About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.

“Oh, about a month,” she said, indifferently.

Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.

But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?

I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?

Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.

Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.

I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”

His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.

But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.

The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.

I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.

Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.

About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.

“Oh, about a month,” she said, indifferently.

Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.

But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?

I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?

Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.

Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.

I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”

His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.

But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.

The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.

I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.

Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.

About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.

“Oh, about a month,” she said, indifferently.

Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.

But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?

I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?

Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.

Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.

I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”

His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.

But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.

The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.

I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.

Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”

I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.

Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”

You would think that, after 30 years, I would recognize a basal cell.

Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.

In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?

The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.

Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?

We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”

We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.

Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.

Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”

Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”

I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.

As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.

Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.

Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”

I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.

Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”

You would think that, after 30 years, I would recognize a basal cell.

Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.

In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?

The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.

Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?

We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”

We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.

Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.

Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”

Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”

I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.

As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.

Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.

Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”

I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.

Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”

You would think that, after 30 years, I would recognize a basal cell.

Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.

In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?

The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.

Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?

We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”

We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.

Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.

Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”

Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”

I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.

As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.

Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.

“Why, oh why, oh why, oh,” my mother used to sing when I was a kid, “Why did I ever leave Ohio?” That's one of those sentimental home-state songs, like “The Missouri Waltz,” “Stars Fell on Alabama,” “I Love New York,” and “See the USA in Your Chevrolet.”

I never had the chance to leave Ohio until last month, when I found myself in Columbus, addressing the Ohio Dermatological Association on its 25th anniversary. Since I started practice almost 30 years ago, that makes me, in a sense, dermatologically older than Ohio. In my talk, “37 Steps to a Successful Practice,” I tried to impart the deep wisdom of experience about how to get ahead in our changing practice environment.

Because 37 is a lot of steps, I limited my remarks to the most crucial: branding, marketing, self-promotion, intensive use of the Internet through creative placement of Web site keywords and Facebook networking, and of course, office decoration according to the principles of Feng Shui.

For some reason, my Ohio colleagues found these thoughtful suggestions laughable. They gave the same response to my innovative plan to make sure patients come back for regular skin checks: an inspection sticker, color-coded by month and affixed to the neck below the angle of the jaw with superglue. This would allow people to peer over the collar of friends and family and say, “Oh, look—you've expired!” Well, I thought it was a good idea. It might even help with pay for performance.

I'm just glad I'm not running for office. Who can predict the responses of these denizens of America's heartland?

Afterward, I had a chance to speak with some of my Ohio colleagues, who seemed to be a refreshingly down-to-earth group. One Mohs surgeon told me that he likes to quiz his fellows by asking them what they consider the most important part of an interview with a prospective patient. After they disgorge what they think he wants to hear (details of the procedure and so on), he shakes his head and says, “Nope. It's showing them you're a good guy who knows what he's doing.”

“I guess we all learn that when we get out in the world,” I said.

“A lot of us don't,” he replied.

The others I met were in practice in Columbus and around the state, mostly in large groups. Several told me that they practice general dermatology. Some seemed almost apologetic when they added that they don't do much cosmetic work, as though that meant they were somehow behind the curve. If so, apologies were unnecessary.

One can certainly get the impression from all the advertising and hype that dermatology is morphing into a species of cosmetic surgery or advanced aesthetics. I provide laser and cosmetic services, carried along like others by the tides of fashion and patient expectations, but I'm still not comfortable with this trend.

Among other things, laser and cosmetic work has brought the modes of marketing into our medical world: coupons, promotions, branding—that sort of thing.

Of course, marketing has made large inroads in traditional medical areas too. Within 10 minutes, the rock station I heard at the gym last week blared two promotions for prominent teaching hospitals providing orthopedic and psychiatric services.

Our sample closets fill with discount coupons to mitigate tiered copays, along with “bundled” products (buy this prescription topical, get this over-the-counter cleanser free!). Nothing wrong with any of this, perhaps, but it just highlights how blurry distinctions have become between medicine and retail.

I'm sure plenty of doctors in Ohio and throughout Middle America perform cosmetic procedures with skill and gusto. Just yesterday a Google ad popped up on my e-mail for a laser center in Indianapolis. (I booked a flight at once.)

It was nice, however, to meet a few colleagues whose practices are still mostly or entirely “just general derm.”

Getting patients to look younger and feel good about themselves is a worthy goal. Someone ought to be doing this. But helping sick people get better is, I think, the reason we went to medical school.

“Why, oh why, oh why, oh,” my mother used to sing when I was a kid, “Why did I ever leave Ohio?” That's one of those sentimental home-state songs, like “The Missouri Waltz,” “Stars Fell on Alabama,” “I Love New York,” and “See the USA in Your Chevrolet.”

I never had the chance to leave Ohio until last month, when I found myself in Columbus, addressing the Ohio Dermatological Association on its 25th anniversary. Since I started practice almost 30 years ago, that makes me, in a sense, dermatologically older than Ohio. In my talk, “37 Steps to a Successful Practice,” I tried to impart the deep wisdom of experience about how to get ahead in our changing practice environment.

Because 37 is a lot of steps, I limited my remarks to the most crucial: branding, marketing, self-promotion, intensive use of the Internet through creative placement of Web site keywords and Facebook networking, and of course, office decoration according to the principles of Feng Shui.

For some reason, my Ohio colleagues found these thoughtful suggestions laughable. They gave the same response to my innovative plan to make sure patients come back for regular skin checks: an inspection sticker, color-coded by month and affixed to the neck below the angle of the jaw with superglue. This would allow people to peer over the collar of friends and family and say, “Oh, look—you've expired!” Well, I thought it was a good idea. It might even help with pay for performance.

I'm just glad I'm not running for office. Who can predict the responses of these denizens of America's heartland?

Afterward, I had a chance to speak with some of my Ohio colleagues, who seemed to be a refreshingly down-to-earth group. One Mohs surgeon told me that he likes to quiz his fellows by asking them what they consider the most important part of an interview with a prospective patient. After they disgorge what they think he wants to hear (details of the procedure and so on), he shakes his head and says, “Nope. It's showing them you're a good guy who knows what he's doing.”

“I guess we all learn that when we get out in the world,” I said.

“A lot of us don't,” he replied.

The others I met were in practice in Columbus and around the state, mostly in large groups. Several told me that they practice general dermatology. Some seemed almost apologetic when they added that they don't do much cosmetic work, as though that meant they were somehow behind the curve. If so, apologies were unnecessary.

One can certainly get the impression from all the advertising and hype that dermatology is morphing into a species of cosmetic surgery or advanced aesthetics. I provide laser and cosmetic services, carried along like others by the tides of fashion and patient expectations, but I'm still not comfortable with this trend.

Among other things, laser and cosmetic work has brought the modes of marketing into our medical world: coupons, promotions, branding—that sort of thing.

Of course, marketing has made large inroads in traditional medical areas too. Within 10 minutes, the rock station I heard at the gym last week blared two promotions for prominent teaching hospitals providing orthopedic and psychiatric services.

Our sample closets fill with discount coupons to mitigate tiered copays, along with “bundled” products (buy this prescription topical, get this over-the-counter cleanser free!). Nothing wrong with any of this, perhaps, but it just highlights how blurry distinctions have become between medicine and retail.

I'm sure plenty of doctors in Ohio and throughout Middle America perform cosmetic procedures with skill and gusto. Just yesterday a Google ad popped up on my e-mail for a laser center in Indianapolis. (I booked a flight at once.)

It was nice, however, to meet a few colleagues whose practices are still mostly or entirely “just general derm.”

Getting patients to look younger and feel good about themselves is a worthy goal. Someone ought to be doing this. But helping sick people get better is, I think, the reason we went to medical school.

“Why, oh why, oh why, oh,” my mother used to sing when I was a kid, “Why did I ever leave Ohio?” That's one of those sentimental home-state songs, like “The Missouri Waltz,” “Stars Fell on Alabama,” “I Love New York,” and “See the USA in Your Chevrolet.”

I never had the chance to leave Ohio until last month, when I found myself in Columbus, addressing the Ohio Dermatological Association on its 25th anniversary. Since I started practice almost 30 years ago, that makes me, in a sense, dermatologically older than Ohio. In my talk, “37 Steps to a Successful Practice,” I tried to impart the deep wisdom of experience about how to get ahead in our changing practice environment.

Because 37 is a lot of steps, I limited my remarks to the most crucial: branding, marketing, self-promotion, intensive use of the Internet through creative placement of Web site keywords and Facebook networking, and of course, office decoration according to the principles of Feng Shui.

For some reason, my Ohio colleagues found these thoughtful suggestions laughable. They gave the same response to my innovative plan to make sure patients come back for regular skin checks: an inspection sticker, color-coded by month and affixed to the neck below the angle of the jaw with superglue. This would allow people to peer over the collar of friends and family and say, “Oh, look—you've expired!” Well, I thought it was a good idea. It might even help with pay for performance.

I'm just glad I'm not running for office. Who can predict the responses of these denizens of America's heartland?

Afterward, I had a chance to speak with some of my Ohio colleagues, who seemed to be a refreshingly down-to-earth group. One Mohs surgeon told me that he likes to quiz his fellows by asking them what they consider the most important part of an interview with a prospective patient. After they disgorge what they think he wants to hear (details of the procedure and so on), he shakes his head and says, “Nope. It's showing them you're a good guy who knows what he's doing.”

“I guess we all learn that when we get out in the world,” I said.

“A lot of us don't,” he replied.

The others I met were in practice in Columbus and around the state, mostly in large groups. Several told me that they practice general dermatology. Some seemed almost apologetic when they added that they don't do much cosmetic work, as though that meant they were somehow behind the curve. If so, apologies were unnecessary.

One can certainly get the impression from all the advertising and hype that dermatology is morphing into a species of cosmetic surgery or advanced aesthetics. I provide laser and cosmetic services, carried along like others by the tides of fashion and patient expectations, but I'm still not comfortable with this trend.

Among other things, laser and cosmetic work has brought the modes of marketing into our medical world: coupons, promotions, branding—that sort of thing.

Of course, marketing has made large inroads in traditional medical areas too. Within 10 minutes, the rock station I heard at the gym last week blared two promotions for prominent teaching hospitals providing orthopedic and psychiatric services.

Our sample closets fill with discount coupons to mitigate tiered copays, along with “bundled” products (buy this prescription topical, get this over-the-counter cleanser free!). Nothing wrong with any of this, perhaps, but it just highlights how blurry distinctions have become between medicine and retail.

I'm sure plenty of doctors in Ohio and throughout Middle America perform cosmetic procedures with skill and gusto. Just yesterday a Google ad popped up on my e-mail for a laser center in Indianapolis. (I booked a flight at once.)

It was nice, however, to meet a few colleagues whose practices are still mostly or entirely “just general derm.”

Getting patients to look younger and feel good about themselves is a worthy goal. Someone ought to be doing this. But helping sick people get better is, I think, the reason we went to medical school.

Joan showed me the muddy pigmentation on the side of her neck.

“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.

“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”

Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.

Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.

“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.

I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.

Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”

I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.

Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?

Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.

My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.

Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)

Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.

Joan showed me the muddy pigmentation on the side of her neck.

“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.

“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”

Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.

Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.

“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.

I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.

Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”

I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.

Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?

Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.

My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.

Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)

Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.

Joan showed me the muddy pigmentation on the side of her neck.

“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.

“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”

Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.

Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.

“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.

I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.

Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”

I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.

Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?

Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.

My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.

Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)

Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.