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Rules of incivility
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Some people are civil; others are not. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.
********
Charlie is 18. His mother is with him.
“I see my colleague prescribed an antibiotic for your acne.”
“No. I stopped the medicine after 2 weeks. It’s not acne.”
“Then what do you think it is?”
“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”
“Prednisone? That is not a good treatment for acne.”
“It’s not acne.”
“If that’s how you feel, then I think you will need to get another opinion.”
“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”
(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)
“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”
“Actually, no.”
“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.
“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.
Later that day Charlie calls back. He asks my secretary where he can post a bad review.
“Try our website,” suggests my staffer.
********
Gwen has many moles. Two were severely dysplastic and required re-excision.
“There is one mole on your back that I think needs to be tested.”
“Why?”
“Because it shows irregularity at the border.”
“I really hate surgery.”
“You may not need more surgery. We should find out, though.”
“I’m not saying you’re doing this just to get more money.”
“Well, thank you for that.”
“I’m not trying to be difficult.”
(But you are succeeding, aren’t you?)
“I also have warts on my finger.”
“I can freeze those for you.”
“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”
“Thank you. I will try to do it correctly.”
“I just want to advocate for myself.”
********
“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”
“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”
“Are all of you incompetent there? I told you my name, didn’t I?”
“Just once more, if you wouldn’t mind.”
“It’s Jomes, J-O-M-E-S. Have you got that?”
“Why, yes, and thank you for your patience. Your appointment is at 1:30.”
“It may rain.”
“Yes, so they say.”
“Well?”
“I’m sorry?”
“I asked you a question.”
“What question?”
“I asked you if it is going to rain.”
“I’m sorry Mr. Jomes. I just book appointments.”
Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.
But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.
I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”
Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Rescue fantasies
In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.
Those of us in the helping professions have fantasies, too, though fewer as times goes by. But the temptation to dream, day or night, never quite goes away. ...
Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.
The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.
Pimecrolimus?!!!
I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.
Esteemed Director,
Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.
My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?
Cordially,
Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.
Curtis does not respond.
My staff calls three times. He doesn’t call back.
I write Curtis a letter. Nothing.
Maybe the Prior Authorization form chased away his eczema.
Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”
I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.
“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.
“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”
“There aren’t?”
“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”
“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”
In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!
A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”
Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.
What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.
Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.
I put my staff on it. Three hours later they find Courtney. In person. It’s all set!
I let Warren know. And then ...
Nothing.
Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.
No response.
My batting average with delusional parasitosis remains an immaculate 0.000.
Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.
And the patient needs to want to be rescued.
Not for nothing do they call them Rescue Fantasies.
Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. He had no disclosures relevant to this column. Write to him at dermnews@mdedge.com.
In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.
Those of us in the helping professions have fantasies, too, though fewer as times goes by. But the temptation to dream, day or night, never quite goes away. ...
Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.
The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.
Pimecrolimus?!!!
I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.
Esteemed Director,
Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.
My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?
Cordially,
Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.
Curtis does not respond.
My staff calls three times. He doesn’t call back.
I write Curtis a letter. Nothing.
Maybe the Prior Authorization form chased away his eczema.
Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”
I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.
“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.
“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”
“There aren’t?”
“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”
“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”
In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!
A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”
Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.
What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.
Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.
I put my staff on it. Three hours later they find Courtney. In person. It’s all set!
I let Warren know. And then ...
Nothing.
Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.
No response.
My batting average with delusional parasitosis remains an immaculate 0.000.
Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.
And the patient needs to want to be rescued.
Not for nothing do they call them Rescue Fantasies.
Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. He had no disclosures relevant to this column. Write to him at dermnews@mdedge.com.
In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.
Those of us in the helping professions have fantasies, too, though fewer as times goes by. But the temptation to dream, day or night, never quite goes away. ...
Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.
The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.
Pimecrolimus?!!!
I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.
Esteemed Director,
Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.
My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?
Cordially,
Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.
Curtis does not respond.
My staff calls three times. He doesn’t call back.
I write Curtis a letter. Nothing.
Maybe the Prior Authorization form chased away his eczema.
Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”
I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.
“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.
“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”
“There aren’t?”
“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”
“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”
In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!
A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”
Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.
What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.
Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.
I put my staff on it. Three hours later they find Courtney. In person. It’s all set!
I let Warren know. And then ...
Nothing.
Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.
No response.
My batting average with delusional parasitosis remains an immaculate 0.000.
Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.
And the patient needs to want to be rescued.
Not for nothing do they call them Rescue Fantasies.
Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. He had no disclosures relevant to this column. Write to him at dermnews@mdedge.com.
I don’t have much use for evidence
.
Of course I am not against evidence. I respect and value evidence. I just have little day-to-day use for it. Maybe your practices are different from mine, but I spend my working days seeing cases ...
Where evidence is irrelevant:
- there is nothing wrong but the patient thinks there might be (an itch, a burning sensation, a mole that may or may not have changed).
- the condition is self-limiting and needs no therapy (viral rashes).
Where evidence could help, but there isn’t any:
- there is no useful available treatment (age-related hair thinning in women).
Where evidence may be statistically significant but clinically trivial:
- pills that make herpes simplex cold sores go away in 6 days instead of 7, acne cream that reduces lesions by 70% instead of 40% (so that after 12 weeks the patient has five pimples instead of eight).
Where evidence is unimpressive or unconvincing (to the patient, who often stops treatment because “it wasn’t working” or “it made me worse”):
- the condition is recurrent, and the patient interprets recurrence as failure (eczema, psoriasis).
- the condition (psoriasis, eczema, acne ) moves around, and the patient interprets success (fewer spots) as failure. (“It’s come in a new place it never came before” or “I never used to get pimples on my jawline.”)
- slam-dunk clearances are few, and instead, every possible permutation in the condition’s course happens – persistence, recurrence, extension, spontaneous involution, going away in one place while proliferating in another, etc. (warts, alopecia areata).
Where patients find other kinds of evidence more compelling than mine:
- “I stopped your cream because calendula/tea tree oil/Vicks VapoRub/apple cider vinegar/avoiding gluten works better” (eczema, rosacea, onychomycosis, etc.). This dynamic is not limited to dermatology. How many Crohn’s patients have I met who say they left their conventional physicians with their standard treatments and now see a naturopath or acupuncturist? Their doctors don’t know they left, or why, because it’s impossible to remember someone who isn’t there, and their patients never told them why they left. These patients tell me they are now “doing better.”
Where evidence is outweighed by other patient considerations:
- topical 5-fluorouracil or imiquimod for superficial basal cells or noninvasive squamous cells in a patient who can’t reach the spot, doesn’t want to be bothered, or just wants the damned thing cut off.
Then, of course, there are cases where evidence is crucial. It’s just that, at the moment, I can’t think of many. Besides which, I’ve lost count of all the patients who had exhaustive food or patch testing, been found sensitive to any number of chemicals and foods – exotic or otherwise – dutifully avoided all of same, yet still break out intermittently and inscrutably, just like all my other atopics.
I’ve concluded that it must be me, or at least the small slice of the planet I work in. Maybe if I practice for 70 years instead of 40, or on five continents instead of the corner of just one, I will figure it all out.
To be clear: I am not a therapeutic nihilist. I want to use verifiably effective treatments for my patients, just as I wish such to be used on me when I need treatment. It’s just that instances in which compelling, decisive evidence makes a crucial difference don’t come up all that often. Evidence applies to populations, whereas I treat people, one at a time.
Meantime, I will muddle along, concerned that one drawback of the emphasis on “evidence” (i.e. statistics) not often noted is its contribution to depersonalizing medical practice, reducing the therapeutic interaction between two people to iterated instances of quantifiable throughput. If you can’t measure it, you didn’t do it and it doesn’t exist. But it does exist. Like every clinician, I see and do it every day.
As Hippocrates supposedly said: Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.
Evidence notwithstanding, judgment remains difficult, mine and the patient’s.
Now that I’m done with evidence, please stay tuned for future columns where I take on motherhood (unacceptably gendered!) and apple pie (fattening!)
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
.
Of course I am not against evidence. I respect and value evidence. I just have little day-to-day use for it. Maybe your practices are different from mine, but I spend my working days seeing cases ...
Where evidence is irrelevant:
- there is nothing wrong but the patient thinks there might be (an itch, a burning sensation, a mole that may or may not have changed).
- the condition is self-limiting and needs no therapy (viral rashes).
Where evidence could help, but there isn’t any:
- there is no useful available treatment (age-related hair thinning in women).
Where evidence may be statistically significant but clinically trivial:
- pills that make herpes simplex cold sores go away in 6 days instead of 7, acne cream that reduces lesions by 70% instead of 40% (so that after 12 weeks the patient has five pimples instead of eight).
Where evidence is unimpressive or unconvincing (to the patient, who often stops treatment because “it wasn’t working” or “it made me worse”):
- the condition is recurrent, and the patient interprets recurrence as failure (eczema, psoriasis).
- the condition (psoriasis, eczema, acne ) moves around, and the patient interprets success (fewer spots) as failure. (“It’s come in a new place it never came before” or “I never used to get pimples on my jawline.”)
- slam-dunk clearances are few, and instead, every possible permutation in the condition’s course happens – persistence, recurrence, extension, spontaneous involution, going away in one place while proliferating in another, etc. (warts, alopecia areata).
Where patients find other kinds of evidence more compelling than mine:
- “I stopped your cream because calendula/tea tree oil/Vicks VapoRub/apple cider vinegar/avoiding gluten works better” (eczema, rosacea, onychomycosis, etc.). This dynamic is not limited to dermatology. How many Crohn’s patients have I met who say they left their conventional physicians with their standard treatments and now see a naturopath or acupuncturist? Their doctors don’t know they left, or why, because it’s impossible to remember someone who isn’t there, and their patients never told them why they left. These patients tell me they are now “doing better.”
Where evidence is outweighed by other patient considerations:
- topical 5-fluorouracil or imiquimod for superficial basal cells or noninvasive squamous cells in a patient who can’t reach the spot, doesn’t want to be bothered, or just wants the damned thing cut off.
Then, of course, there are cases where evidence is crucial. It’s just that, at the moment, I can’t think of many. Besides which, I’ve lost count of all the patients who had exhaustive food or patch testing, been found sensitive to any number of chemicals and foods – exotic or otherwise – dutifully avoided all of same, yet still break out intermittently and inscrutably, just like all my other atopics.
I’ve concluded that it must be me, or at least the small slice of the planet I work in. Maybe if I practice for 70 years instead of 40, or on five continents instead of the corner of just one, I will figure it all out.
To be clear: I am not a therapeutic nihilist. I want to use verifiably effective treatments for my patients, just as I wish such to be used on me when I need treatment. It’s just that instances in which compelling, decisive evidence makes a crucial difference don’t come up all that often. Evidence applies to populations, whereas I treat people, one at a time.
Meantime, I will muddle along, concerned that one drawback of the emphasis on “evidence” (i.e. statistics) not often noted is its contribution to depersonalizing medical practice, reducing the therapeutic interaction between two people to iterated instances of quantifiable throughput. If you can’t measure it, you didn’t do it and it doesn’t exist. But it does exist. Like every clinician, I see and do it every day.
As Hippocrates supposedly said: Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.
Evidence notwithstanding, judgment remains difficult, mine and the patient’s.
Now that I’m done with evidence, please stay tuned for future columns where I take on motherhood (unacceptably gendered!) and apple pie (fattening!)
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
.
Of course I am not against evidence. I respect and value evidence. I just have little day-to-day use for it. Maybe your practices are different from mine, but I spend my working days seeing cases ...
Where evidence is irrelevant:
- there is nothing wrong but the patient thinks there might be (an itch, a burning sensation, a mole that may or may not have changed).
- the condition is self-limiting and needs no therapy (viral rashes).
Where evidence could help, but there isn’t any:
- there is no useful available treatment (age-related hair thinning in women).
Where evidence may be statistically significant but clinically trivial:
- pills that make herpes simplex cold sores go away in 6 days instead of 7, acne cream that reduces lesions by 70% instead of 40% (so that after 12 weeks the patient has five pimples instead of eight).
Where evidence is unimpressive or unconvincing (to the patient, who often stops treatment because “it wasn’t working” or “it made me worse”):
- the condition is recurrent, and the patient interprets recurrence as failure (eczema, psoriasis).
- the condition (psoriasis, eczema, acne ) moves around, and the patient interprets success (fewer spots) as failure. (“It’s come in a new place it never came before” or “I never used to get pimples on my jawline.”)
- slam-dunk clearances are few, and instead, every possible permutation in the condition’s course happens – persistence, recurrence, extension, spontaneous involution, going away in one place while proliferating in another, etc. (warts, alopecia areata).
Where patients find other kinds of evidence more compelling than mine:
- “I stopped your cream because calendula/tea tree oil/Vicks VapoRub/apple cider vinegar/avoiding gluten works better” (eczema, rosacea, onychomycosis, etc.). This dynamic is not limited to dermatology. How many Crohn’s patients have I met who say they left their conventional physicians with their standard treatments and now see a naturopath or acupuncturist? Their doctors don’t know they left, or why, because it’s impossible to remember someone who isn’t there, and their patients never told them why they left. These patients tell me they are now “doing better.”
Where evidence is outweighed by other patient considerations:
- topical 5-fluorouracil or imiquimod for superficial basal cells or noninvasive squamous cells in a patient who can’t reach the spot, doesn’t want to be bothered, or just wants the damned thing cut off.
Then, of course, there are cases where evidence is crucial. It’s just that, at the moment, I can’t think of many. Besides which, I’ve lost count of all the patients who had exhaustive food or patch testing, been found sensitive to any number of chemicals and foods – exotic or otherwise – dutifully avoided all of same, yet still break out intermittently and inscrutably, just like all my other atopics.
I’ve concluded that it must be me, or at least the small slice of the planet I work in. Maybe if I practice for 70 years instead of 40, or on five continents instead of the corner of just one, I will figure it all out.
To be clear: I am not a therapeutic nihilist. I want to use verifiably effective treatments for my patients, just as I wish such to be used on me when I need treatment. It’s just that instances in which compelling, decisive evidence makes a crucial difference don’t come up all that often. Evidence applies to populations, whereas I treat people, one at a time.
Meantime, I will muddle along, concerned that one drawback of the emphasis on “evidence” (i.e. statistics) not often noted is its contribution to depersonalizing medical practice, reducing the therapeutic interaction between two people to iterated instances of quantifiable throughput. If you can’t measure it, you didn’t do it and it doesn’t exist. But it does exist. Like every clinician, I see and do it every day.
As Hippocrates supposedly said: Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.
Evidence notwithstanding, judgment remains difficult, mine and the patient’s.
Now that I’m done with evidence, please stay tuned for future columns where I take on motherhood (unacceptably gendered!) and apple pie (fattening!)
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Fear
Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.
Boris has a spot on his nose. I call with test results.
“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”
“Skin cancer?”
“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”
“Will I have to stay in the hospital?”
“No, it’s done under local anesthesia. You get it done and go home.”
“Is it urgent?”
“It can wait a few weeks. Just call for an appointment.”
“Will it be done in the hospital itself, or in another building?”
One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”
It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.
Stella is more perplexing than Boris, not to mention more challenging.
“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”
“Taken care of?”
“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”
“A healer?”
“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”
“With due respect, I don’t think she did.”
“Why do you say that?”
“Because it’s still there on your forehead. I can see it.”
Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.
The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.
I call Stella.
“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”
“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”
“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”
Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”
“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”
Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...
“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”
“Of course,” says Stella, “that goes without saying.”
“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”
We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.
Stella’s faith in her remote healer seems like one way of abetting denial and addressing fear, one step beyond just pretending the symptom or sign simply isn’t there. How much more obvious can a problem be than a black spot on your forehead?
Dealing with it may be wearying, or impossible. But it’s part of our job, because it’s always there.
Besides, we should be able to relate. Doctors know fear too, don’t we?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.
Boris has a spot on his nose. I call with test results.
“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”
“Skin cancer?”
“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”
“Will I have to stay in the hospital?”
“No, it’s done under local anesthesia. You get it done and go home.”
“Is it urgent?”
“It can wait a few weeks. Just call for an appointment.”
“Will it be done in the hospital itself, or in another building?”
One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”
It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.
Stella is more perplexing than Boris, not to mention more challenging.
“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”
“Taken care of?”
“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”
“A healer?”
“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”
“With due respect, I don’t think she did.”
“Why do you say that?”
“Because it’s still there on your forehead. I can see it.”
Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.
The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.
I call Stella.
“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”
“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”
“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”
Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”
“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”
Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...
“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”
“Of course,” says Stella, “that goes without saying.”
“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”
We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.
Stella’s faith in her remote healer seems like one way of abetting denial and addressing fear, one step beyond just pretending the symptom or sign simply isn’t there. How much more obvious can a problem be than a black spot on your forehead?
Dealing with it may be wearying, or impossible. But it’s part of our job, because it’s always there.
Besides, we should be able to relate. Doctors know fear too, don’t we?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.
Boris has a spot on his nose. I call with test results.
“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”
“Skin cancer?”
“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”
“Will I have to stay in the hospital?”
“No, it’s done under local anesthesia. You get it done and go home.”
“Is it urgent?”
“It can wait a few weeks. Just call for an appointment.”
“Will it be done in the hospital itself, or in another building?”
One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”
It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.
Stella is more perplexing than Boris, not to mention more challenging.
“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”
“Taken care of?”
“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”
“A healer?”
“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”
“With due respect, I don’t think she did.”
“Why do you say that?”
“Because it’s still there on your forehead. I can see it.”
Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.
The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.
I call Stella.
“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”
“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”
“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”
Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”
“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”
Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...
“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”
“Of course,” says Stella, “that goes without saying.”
“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”
We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.
Stella’s faith in her remote healer seems like one way of abetting denial and addressing fear, one step beyond just pretending the symptom or sign simply isn’t there. How much more obvious can a problem be than a black spot on your forehead?
Dealing with it may be wearying, or impossible. But it’s part of our job, because it’s always there.
Besides, we should be able to relate. Doctors know fear too, don’t we?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Retail neurosis
When I stopped by last August to pick up new eyeglass lenses, Harold the optician sat alone in his shop.
“Business slow in the summer?” I asked.
Harold looked morose. “I knew it would be like this when I bought the business,” he said. “We’re open Saturdays, but summers I close at 2. Everybody’s at the Cape.”
Working in retail makes people more neurotic than necessary. I should know. I’ve been in retail for 40 years.
My patient Myrtle once explained to me how retail induces neurosis by deforming incentives. Myrtle used to work in management at a big department store. (Older readers may recall going to stores in buildings to buy things. The same readers may recall newspapers.)
“The month between Thanksgiving and Christmas makes or breaks the whole year,” Myrtle said. “If you do worse than last year, you feel bad. But if you do better than last year you also feel bad, because you worry you won’t be able to top it next year.”
She paused. “I guess that’s not a very healthy way to live, is it?”
I was too polite to agree.
Early in my career I had few patients on my schedule, maybe five on a good day. Then three of them would cancel. That was the start of my retail neurosis. Of course, I was a solo practitioner who started my own practice. The likes of me will someday be found in a museum, stuffed and mounted, along with other extinct species, under the label Medicus Cutaneous Solipsisticus (North America c. 20th century).
Over time, I got busier and dropped each of my eleven part-time jobs. By now I’ve been busy for decades, even though I’ve never had much of a waiting list. Don’t know why that is, but it no longer matters.
Except it does, psychologically. You won’t find this code in the DSM, but my working definition for the malady I describe is as follows:
Retail Neurosis (billable ICD-10 code F48.8. Other unspecified nonpsychotic mental disorders, along with writer’s block and psychasthenia):
Definition: The unquenchable fear that even the tiniest break in an endless churn of patients means that all patients will disappear later this afternoon, reverting the practice to the empty, formless void from whence it came. Other than retirement, there is no treatment for this disorder. And maybe not then either.
You might think to classify Retail Neurosis under Financial Insecurity, but that disorder has a different code. (F40.248, Fear of Failing, Life-Circumstance Problem). After all, a single well-remunerated patient (53 actinic keratoses!) can outreimburse half a dozen others with only E/M codes and big deductibles. Treat one of the former, take the rest of the hour off, and you’re financially just as well off, or even better. Yes?
No. Taking the rest of the hour off leaves you with too much time to ponder what every retailer knows: Each idle minute is another lost chance to make another sale and generate revenue. That minute (and revenue) can never be retrieved. Never!
As Myrtle would say, “Not a very healthy way to live, is it?”
Maybe not, but here as elsewhere, knowing something and fixing it are different things. Besides, brisk retail business brings a buzz, along with a sense of mastery and accomplishment, which is pleasantly addictive. Until it isn’t.
New generations of physicians and other medical providers will work in different settings than mine; they will be wage-earners in large organizations. These conglomerations bring their own neurosis-inducing incentives. Their managers measure providers’ productivity in various deforming and crazy-making ways. (See RVU-penia, ICD-10 M26.56: “Nonworking side interference.” This is actually a dental code that refers to jaw position, but billing demands creativity.) Practitioner anxieties will center on being docked for not generating enough relative value units or for failure to bundle enough comorbidities for maximizing capitation payments (e.g., Plaque Psoriasis plus Morbid Obesity plus Writer’s Block). But the youngsters will learn to get along. They’ll have to.
“Taking any time off this summer?” I asked my optician Harold.
“My wife and daughter are going out to Michigan in mid-August,” he said.
“Aren’t you going with them?”
“I can’t swing it that week,” he said. “By then, people are coming back to town, getting their kids ready for school. If I go away, I would miss some customers.”
Harold, you are my kind of guy!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
When I stopped by last August to pick up new eyeglass lenses, Harold the optician sat alone in his shop.
“Business slow in the summer?” I asked.
Harold looked morose. “I knew it would be like this when I bought the business,” he said. “We’re open Saturdays, but summers I close at 2. Everybody’s at the Cape.”
Working in retail makes people more neurotic than necessary. I should know. I’ve been in retail for 40 years.
My patient Myrtle once explained to me how retail induces neurosis by deforming incentives. Myrtle used to work in management at a big department store. (Older readers may recall going to stores in buildings to buy things. The same readers may recall newspapers.)
“The month between Thanksgiving and Christmas makes or breaks the whole year,” Myrtle said. “If you do worse than last year, you feel bad. But if you do better than last year you also feel bad, because you worry you won’t be able to top it next year.”
She paused. “I guess that’s not a very healthy way to live, is it?”
I was too polite to agree.
Early in my career I had few patients on my schedule, maybe five on a good day. Then three of them would cancel. That was the start of my retail neurosis. Of course, I was a solo practitioner who started my own practice. The likes of me will someday be found in a museum, stuffed and mounted, along with other extinct species, under the label Medicus Cutaneous Solipsisticus (North America c. 20th century).
Over time, I got busier and dropped each of my eleven part-time jobs. By now I’ve been busy for decades, even though I’ve never had much of a waiting list. Don’t know why that is, but it no longer matters.
Except it does, psychologically. You won’t find this code in the DSM, but my working definition for the malady I describe is as follows:
Retail Neurosis (billable ICD-10 code F48.8. Other unspecified nonpsychotic mental disorders, along with writer’s block and psychasthenia):
Definition: The unquenchable fear that even the tiniest break in an endless churn of patients means that all patients will disappear later this afternoon, reverting the practice to the empty, formless void from whence it came. Other than retirement, there is no treatment for this disorder. And maybe not then either.
You might think to classify Retail Neurosis under Financial Insecurity, but that disorder has a different code. (F40.248, Fear of Failing, Life-Circumstance Problem). After all, a single well-remunerated patient (53 actinic keratoses!) can outreimburse half a dozen others with only E/M codes and big deductibles. Treat one of the former, take the rest of the hour off, and you’re financially just as well off, or even better. Yes?
No. Taking the rest of the hour off leaves you with too much time to ponder what every retailer knows: Each idle minute is another lost chance to make another sale and generate revenue. That minute (and revenue) can never be retrieved. Never!
As Myrtle would say, “Not a very healthy way to live, is it?”
Maybe not, but here as elsewhere, knowing something and fixing it are different things. Besides, brisk retail business brings a buzz, along with a sense of mastery and accomplishment, which is pleasantly addictive. Until it isn’t.
New generations of physicians and other medical providers will work in different settings than mine; they will be wage-earners in large organizations. These conglomerations bring their own neurosis-inducing incentives. Their managers measure providers’ productivity in various deforming and crazy-making ways. (See RVU-penia, ICD-10 M26.56: “Nonworking side interference.” This is actually a dental code that refers to jaw position, but billing demands creativity.) Practitioner anxieties will center on being docked for not generating enough relative value units or for failure to bundle enough comorbidities for maximizing capitation payments (e.g., Plaque Psoriasis plus Morbid Obesity plus Writer’s Block). But the youngsters will learn to get along. They’ll have to.
“Taking any time off this summer?” I asked my optician Harold.
“My wife and daughter are going out to Michigan in mid-August,” he said.
“Aren’t you going with them?”
“I can’t swing it that week,” he said. “By then, people are coming back to town, getting their kids ready for school. If I go away, I would miss some customers.”
Harold, you are my kind of guy!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
When I stopped by last August to pick up new eyeglass lenses, Harold the optician sat alone in his shop.
“Business slow in the summer?” I asked.
Harold looked morose. “I knew it would be like this when I bought the business,” he said. “We’re open Saturdays, but summers I close at 2. Everybody’s at the Cape.”
Working in retail makes people more neurotic than necessary. I should know. I’ve been in retail for 40 years.
My patient Myrtle once explained to me how retail induces neurosis by deforming incentives. Myrtle used to work in management at a big department store. (Older readers may recall going to stores in buildings to buy things. The same readers may recall newspapers.)
“The month between Thanksgiving and Christmas makes or breaks the whole year,” Myrtle said. “If you do worse than last year, you feel bad. But if you do better than last year you also feel bad, because you worry you won’t be able to top it next year.”
She paused. “I guess that’s not a very healthy way to live, is it?”
I was too polite to agree.
Early in my career I had few patients on my schedule, maybe five on a good day. Then three of them would cancel. That was the start of my retail neurosis. Of course, I was a solo practitioner who started my own practice. The likes of me will someday be found in a museum, stuffed and mounted, along with other extinct species, under the label Medicus Cutaneous Solipsisticus (North America c. 20th century).
Over time, I got busier and dropped each of my eleven part-time jobs. By now I’ve been busy for decades, even though I’ve never had much of a waiting list. Don’t know why that is, but it no longer matters.
Except it does, psychologically. You won’t find this code in the DSM, but my working definition for the malady I describe is as follows:
Retail Neurosis (billable ICD-10 code F48.8. Other unspecified nonpsychotic mental disorders, along with writer’s block and psychasthenia):
Definition: The unquenchable fear that even the tiniest break in an endless churn of patients means that all patients will disappear later this afternoon, reverting the practice to the empty, formless void from whence it came. Other than retirement, there is no treatment for this disorder. And maybe not then either.
You might think to classify Retail Neurosis under Financial Insecurity, but that disorder has a different code. (F40.248, Fear of Failing, Life-Circumstance Problem). After all, a single well-remunerated patient (53 actinic keratoses!) can outreimburse half a dozen others with only E/M codes and big deductibles. Treat one of the former, take the rest of the hour off, and you’re financially just as well off, or even better. Yes?
No. Taking the rest of the hour off leaves you with too much time to ponder what every retailer knows: Each idle minute is another lost chance to make another sale and generate revenue. That minute (and revenue) can never be retrieved. Never!
As Myrtle would say, “Not a very healthy way to live, is it?”
Maybe not, but here as elsewhere, knowing something and fixing it are different things. Besides, brisk retail business brings a buzz, along with a sense of mastery and accomplishment, which is pleasantly addictive. Until it isn’t.
New generations of physicians and other medical providers will work in different settings than mine; they will be wage-earners in large organizations. These conglomerations bring their own neurosis-inducing incentives. Their managers measure providers’ productivity in various deforming and crazy-making ways. (See RVU-penia, ICD-10 M26.56: “Nonworking side interference.” This is actually a dental code that refers to jaw position, but billing demands creativity.) Practitioner anxieties will center on being docked for not generating enough relative value units or for failure to bundle enough comorbidities for maximizing capitation payments (e.g., Plaque Psoriasis plus Morbid Obesity plus Writer’s Block). But the youngsters will learn to get along. They’ll have to.
“Taking any time off this summer?” I asked my optician Harold.
“My wife and daughter are going out to Michigan in mid-August,” he said.
“Aren’t you going with them?”
“I can’t swing it that week,” he said. “By then, people are coming back to town, getting their kids ready for school. If I go away, I would miss some customers.”
Harold, you are my kind of guy!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
“I go by thickness”
One of our favorite comics was Steven Wright, who made it to the Tonight Show with Johnny Carson. (Google him.)
Wright’s offbeat humor was quirky and a bit philosophical, and was delivered in a deadpan, mumbled monotone. For instance:
When I got to school, the teacher said, “The socks you’re wearing don’t match. They’re two different colors.”
I said, “I go by thickness.”
That punchline goes pop in your head, like a shy little firecracker: How come it never occurred to me to look at it that way?
I thought of Steven Wright recently while I was enrolling Stacy, a 20-year-old, in the iPledge program for a planned course of isotretinoin. Stacy told me she is sexually active and has an IUD.
“When you start the medicine next month,” I told her, “you’ll need to pick a second form of contraception.”
Stacy looked bewildered. When I’ve made that statement to a thousand previous patients, none of them ever looked bewildered.
“I mean,” I said, “besides the IUD, you’ll need to use a second type of contraception, to be sure you don’t get pregnant. You could choose condoms, or one of the other types listed in the booklet I gave you.”
That didn’t seem to help. Stacey hemmed a bit. “Does that mean I have to tell you ... ?”
“Yes, you have to pick another form of birth control and tell me which one it is.”
“I have to tell you every time?”
My go-by-thickness moment – I finally got it. “NO,” I said. “You do NOT have to tell me which second contraceptive you use every time you have sex!”
Steven Wright would be proud of Stacy. Isotretinoin came out in 1982, but nobody ever thought of “choose a second type of contraception” that way before. Stacy goes by retail.
That case reminded of another out-of-left field question I heard for the first – and only – time almost 40 years ago. I had prescribed a cream for a young man.
“Can I get it refilled?” he asked.
“Sure,” I said.
“How do I refill it?” he asked.
“You take it back to the pharmacy, and they refill it for you,” I said.
“But how do they refill it?”
“You show them what you need, and they refill it.”
“But how?”
“Why do you keep asking me that?”
“The tube is going to be all scrunched up from my squeezing it,” he said. “How do they get the new cream back in?”
Well son of a gun, “refill” could mean that, couldn’t it? If you go by thickness.
In idle moments I like to let novel perspectives such as those roll around in my head. The other day I accompanied a relative to an emergency department. While waiting in triage for 5 hours, I looked up and saw a sign on the wall, in big, blue letters: “Support ED Research!”
That puzzled me. I know it can be an important problem, but why the dickens would someone come to an emergency department for erectile dysfunction?
I go by acronyms.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
One of our favorite comics was Steven Wright, who made it to the Tonight Show with Johnny Carson. (Google him.)
Wright’s offbeat humor was quirky and a bit philosophical, and was delivered in a deadpan, mumbled monotone. For instance:
When I got to school, the teacher said, “The socks you’re wearing don’t match. They’re two different colors.”
I said, “I go by thickness.”
That punchline goes pop in your head, like a shy little firecracker: How come it never occurred to me to look at it that way?
I thought of Steven Wright recently while I was enrolling Stacy, a 20-year-old, in the iPledge program for a planned course of isotretinoin. Stacy told me she is sexually active and has an IUD.
“When you start the medicine next month,” I told her, “you’ll need to pick a second form of contraception.”
Stacy looked bewildered. When I’ve made that statement to a thousand previous patients, none of them ever looked bewildered.
“I mean,” I said, “besides the IUD, you’ll need to use a second type of contraception, to be sure you don’t get pregnant. You could choose condoms, or one of the other types listed in the booklet I gave you.”
That didn’t seem to help. Stacey hemmed a bit. “Does that mean I have to tell you ... ?”
“Yes, you have to pick another form of birth control and tell me which one it is.”
“I have to tell you every time?”
My go-by-thickness moment – I finally got it. “NO,” I said. “You do NOT have to tell me which second contraceptive you use every time you have sex!”
Steven Wright would be proud of Stacy. Isotretinoin came out in 1982, but nobody ever thought of “choose a second type of contraception” that way before. Stacy goes by retail.
That case reminded of another out-of-left field question I heard for the first – and only – time almost 40 years ago. I had prescribed a cream for a young man.
“Can I get it refilled?” he asked.
“Sure,” I said.
“How do I refill it?” he asked.
“You take it back to the pharmacy, and they refill it for you,” I said.
“But how do they refill it?”
“You show them what you need, and they refill it.”
“But how?”
“Why do you keep asking me that?”
“The tube is going to be all scrunched up from my squeezing it,” he said. “How do they get the new cream back in?”
Well son of a gun, “refill” could mean that, couldn’t it? If you go by thickness.
In idle moments I like to let novel perspectives such as those roll around in my head. The other day I accompanied a relative to an emergency department. While waiting in triage for 5 hours, I looked up and saw a sign on the wall, in big, blue letters: “Support ED Research!”
That puzzled me. I know it can be an important problem, but why the dickens would someone come to an emergency department for erectile dysfunction?
I go by acronyms.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
One of our favorite comics was Steven Wright, who made it to the Tonight Show with Johnny Carson. (Google him.)
Wright’s offbeat humor was quirky and a bit philosophical, and was delivered in a deadpan, mumbled monotone. For instance:
When I got to school, the teacher said, “The socks you’re wearing don’t match. They’re two different colors.”
I said, “I go by thickness.”
That punchline goes pop in your head, like a shy little firecracker: How come it never occurred to me to look at it that way?
I thought of Steven Wright recently while I was enrolling Stacy, a 20-year-old, in the iPledge program for a planned course of isotretinoin. Stacy told me she is sexually active and has an IUD.
“When you start the medicine next month,” I told her, “you’ll need to pick a second form of contraception.”
Stacy looked bewildered. When I’ve made that statement to a thousand previous patients, none of them ever looked bewildered.
“I mean,” I said, “besides the IUD, you’ll need to use a second type of contraception, to be sure you don’t get pregnant. You could choose condoms, or one of the other types listed in the booklet I gave you.”
That didn’t seem to help. Stacey hemmed a bit. “Does that mean I have to tell you ... ?”
“Yes, you have to pick another form of birth control and tell me which one it is.”
“I have to tell you every time?”
My go-by-thickness moment – I finally got it. “NO,” I said. “You do NOT have to tell me which second contraceptive you use every time you have sex!”
Steven Wright would be proud of Stacy. Isotretinoin came out in 1982, but nobody ever thought of “choose a second type of contraception” that way before. Stacy goes by retail.
That case reminded of another out-of-left field question I heard for the first – and only – time almost 40 years ago. I had prescribed a cream for a young man.
“Can I get it refilled?” he asked.
“Sure,” I said.
“How do I refill it?” he asked.
“You take it back to the pharmacy, and they refill it for you,” I said.
“But how do they refill it?”
“You show them what you need, and they refill it.”
“But how?”
“Why do you keep asking me that?”
“The tube is going to be all scrunched up from my squeezing it,” he said. “How do they get the new cream back in?”
Well son of a gun, “refill” could mean that, couldn’t it? If you go by thickness.
In idle moments I like to let novel perspectives such as those roll around in my head. The other day I accompanied a relative to an emergency department. While waiting in triage for 5 hours, I looked up and saw a sign on the wall, in big, blue letters: “Support ED Research!”
That puzzled me. I know it can be an important problem, but why the dickens would someone come to an emergency department for erectile dysfunction?
I go by acronyms.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Patient, heal thyself!
Octavio has prostate cancer. His prostate growth is large but localized.
“What do your doctors suggest?” I asked him.
“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”
“How will you decide?”
“I’ll do some reading,” he said.
“What about the doctor who sent you to them?”
“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”
Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:
. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.
This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:
1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”
2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”
Is “trying to influence” the same as making the decision for the patient?
Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.
Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?
You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.
Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?
Octavio chose surgery. I asked him how he decided.
“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”
Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.
You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.
“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”
Did I influence her health care decision? Sure. Guilty as charged, with no apologies. When I am a patient, I want nothing less for myself: sympathetic, experienced guidance, shared by someone who knows me and appears to care one way or the other how I do.
Lord preserve us, doctors and patients both, from dogmatists who would demand otherwise.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Octavio has prostate cancer. His prostate growth is large but localized.
“What do your doctors suggest?” I asked him.
“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”
“How will you decide?”
“I’ll do some reading,” he said.
“What about the doctor who sent you to them?”
“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”
Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:
. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.
This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:
1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”
2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”
Is “trying to influence” the same as making the decision for the patient?
Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.
Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?
You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.
Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?
Octavio chose surgery. I asked him how he decided.
“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”
Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.
You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.
“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”
Did I influence her health care decision? Sure. Guilty as charged, with no apologies. When I am a patient, I want nothing less for myself: sympathetic, experienced guidance, shared by someone who knows me and appears to care one way or the other how I do.
Lord preserve us, doctors and patients both, from dogmatists who would demand otherwise.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Octavio has prostate cancer. His prostate growth is large but localized.
“What do your doctors suggest?” I asked him.
“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”
“How will you decide?”
“I’ll do some reading,” he said.
“What about the doctor who sent you to them?”
“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”
Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:
. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.
This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:
1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”
2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”
Is “trying to influence” the same as making the decision for the patient?
Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.
Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?
You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.
Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?
Octavio chose surgery. I asked him how he decided.
“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”
Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.
You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.
“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”
Did I influence her health care decision? Sure. Guilty as charged, with no apologies. When I am a patient, I want nothing less for myself: sympathetic, experienced guidance, shared by someone who knows me and appears to care one way or the other how I do.
Lord preserve us, doctors and patients both, from dogmatists who would demand otherwise.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Tyranny by the numbers
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Fungal failure
Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”
“How’s it going?” I asked.
Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”
I too, dear colleagues, have had a life’s ambition, secret until right now:
Alas, like Ed’s, my work is not yet done.
I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.
1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.
2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.
3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.
4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.
5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.
6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!
7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.
8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.
9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.
10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?
And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.
In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.
Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”
I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.
Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.
But then, there always is.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”
“How’s it going?” I asked.
Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”
I too, dear colleagues, have had a life’s ambition, secret until right now:
Alas, like Ed’s, my work is not yet done.
I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.
1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.
2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.
3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.
4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.
5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.
6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!
7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.
8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.
9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.
10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?
And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.
In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.
Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”
I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.
Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.
But then, there always is.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”
“How’s it going?” I asked.
Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”
I too, dear colleagues, have had a life’s ambition, secret until right now:
Alas, like Ed’s, my work is not yet done.
I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.
1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.
2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.
3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.
4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.
5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.
6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!
7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.
8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.
9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.
10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?
And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.
In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.
Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”
I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.
Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.
But then, there always is.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
An iPledge Halloween
It was a dark and stormy night.
OK, it was a warm and sunny afternoon. But Halloween was approaching. Strange things happen. Plus, the patient’s name was Ichabod ...
OK, his name was Jerry. Jerry came to Boston from Chula Taco, Calif., to study at CIT, the famed Boston Chipotle Institute of Technology. He’d finished 4 months of isotretinoin and needed one more.
I asked him to call iPledge to request a transfer to me. He called back later to say that This seemed odd, since his pills had only run out 3 days before.
Having confirmed his name, address, telephone number, and the last four digits of his social security number, I tried enrolling him on iPledge at 5:30 p.m. (Cue: thunder and lightning), expecting to get a request for an override code. Instead the screen just asked for his iPledge number (you have to use the old one, you know). I called iPledge (my favorite pastime), identified myself by the usual means (Full name. iPledge ID number. Date of personal significance. Office telephone. Thank you. How can I help you?).
I explained my dilemma. The representative asked that I verify Jerry’s identity. I gave her his name, date of birth, and the last four of his social.
“We have his name and date of birth,” she said, “but the social security digits don’t match.” She asked for his phone number, but his Boston number didn’t match what she had. “Do you have his address?” she asked. I did not, since he’d given me his Boston address, not his California one.
I left her on hold and called Jerry on my cell. He confirmed that the social security digits he’d given me were correct. He gave me his mother’s cell phone number, but that also turned out not to be what iPledge had on file.
“What other identifying information can I give you?” I asked the iPledge rep. “How about his home address?” she said. Back to my cell: “Jerry, what’s your home address?” “It’s 2470 Chalupa Drive, Chula Taco, California 9090909-090909,” he said.
I repeated that to the iPledge representative. “Please hold a moment,” she said.
She was back. “The street address is correct,” she said, “The ZIP is correct. But the town is wrong.”
The town is wrong? If Jerry didn’t know either the last four of his social or his town, how did he get Amazon deliveries? Was this identity theft by an Accutane seeker? Maybe Jerry was really a Russian spy with dry lips posing as an acne patient! (Cue: screeches, howls, more thunder.)
“Can you tell me which town you have listed for him?” I asked iPledge.
“No,” she said, “because you haven’t identified him properly yet,” (emphasis added).
Back to the cell: “Jerry, are you sure you know what town you live in?” He insisted he did. (But then, so would a spy, wouldn’t he?)
In near despair, I returned to the iPledge rep. “I really want to get this patient his medication, “I said. “And I really want to go home. Can you help either of us?”
“Let me get my supervisor,” she said. “This may take a few minutes.” I hung up on Jerry and, in a blaze of multitasking, filled out three Prior Authorization forms for clindamycin gel.
“I found your patient,” said the rep, returning at last. “Not only that, I was able to reregister him in the iPledge program. Want to know his iPledge number?
Of course!
“Now that he’s registered,” I said, “could you give me the name of the town you have him listed as living in on Chalupa Drive?”
“Sure,” she said, “We have him in Rancho Carmen Miranda. Can help you with anything else today?”
“No, thanks ...”
“Would you be willing to take a 2-minute survey ...?”
“No, but thank you very much!” I said, hanging up in triumph. (Cue: sunshine, violins.)
Back to the cell: “Jerry, you’re in! Here’s your iPledge number.”
“Thanks, Doc.”
“By the way, Jerry, iPledge has you living in the town of Rancho Carmen Miranda. Do you live there?”
“No,” said Jerry. “I don’t.”
“Well, Jerry, for 1 more month, for federal purposes, you do!”
I’m sure there’s a good explanation for all this. I just don’t want to know it. Just pass the candy corn.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
It was a dark and stormy night.
OK, it was a warm and sunny afternoon. But Halloween was approaching. Strange things happen. Plus, the patient’s name was Ichabod ...
OK, his name was Jerry. Jerry came to Boston from Chula Taco, Calif., to study at CIT, the famed Boston Chipotle Institute of Technology. He’d finished 4 months of isotretinoin and needed one more.
I asked him to call iPledge to request a transfer to me. He called back later to say that This seemed odd, since his pills had only run out 3 days before.
Having confirmed his name, address, telephone number, and the last four digits of his social security number, I tried enrolling him on iPledge at 5:30 p.m. (Cue: thunder and lightning), expecting to get a request for an override code. Instead the screen just asked for his iPledge number (you have to use the old one, you know). I called iPledge (my favorite pastime), identified myself by the usual means (Full name. iPledge ID number. Date of personal significance. Office telephone. Thank you. How can I help you?).
I explained my dilemma. The representative asked that I verify Jerry’s identity. I gave her his name, date of birth, and the last four of his social.
“We have his name and date of birth,” she said, “but the social security digits don’t match.” She asked for his phone number, but his Boston number didn’t match what she had. “Do you have his address?” she asked. I did not, since he’d given me his Boston address, not his California one.
I left her on hold and called Jerry on my cell. He confirmed that the social security digits he’d given me were correct. He gave me his mother’s cell phone number, but that also turned out not to be what iPledge had on file.
“What other identifying information can I give you?” I asked the iPledge rep. “How about his home address?” she said. Back to my cell: “Jerry, what’s your home address?” “It’s 2470 Chalupa Drive, Chula Taco, California 9090909-090909,” he said.
I repeated that to the iPledge representative. “Please hold a moment,” she said.
She was back. “The street address is correct,” she said, “The ZIP is correct. But the town is wrong.”
The town is wrong? If Jerry didn’t know either the last four of his social or his town, how did he get Amazon deliveries? Was this identity theft by an Accutane seeker? Maybe Jerry was really a Russian spy with dry lips posing as an acne patient! (Cue: screeches, howls, more thunder.)
“Can you tell me which town you have listed for him?” I asked iPledge.
“No,” she said, “because you haven’t identified him properly yet,” (emphasis added).
Back to the cell: “Jerry, are you sure you know what town you live in?” He insisted he did. (But then, so would a spy, wouldn’t he?)
In near despair, I returned to the iPledge rep. “I really want to get this patient his medication, “I said. “And I really want to go home. Can you help either of us?”
“Let me get my supervisor,” she said. “This may take a few minutes.” I hung up on Jerry and, in a blaze of multitasking, filled out three Prior Authorization forms for clindamycin gel.
“I found your patient,” said the rep, returning at last. “Not only that, I was able to reregister him in the iPledge program. Want to know his iPledge number?
Of course!
“Now that he’s registered,” I said, “could you give me the name of the town you have him listed as living in on Chalupa Drive?”
“Sure,” she said, “We have him in Rancho Carmen Miranda. Can help you with anything else today?”
“No, thanks ...”
“Would you be willing to take a 2-minute survey ...?”
“No, but thank you very much!” I said, hanging up in triumph. (Cue: sunshine, violins.)
Back to the cell: “Jerry, you’re in! Here’s your iPledge number.”
“Thanks, Doc.”
“By the way, Jerry, iPledge has you living in the town of Rancho Carmen Miranda. Do you live there?”
“No,” said Jerry. “I don’t.”
“Well, Jerry, for 1 more month, for federal purposes, you do!”
I’m sure there’s a good explanation for all this. I just don’t want to know it. Just pass the candy corn.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
It was a dark and stormy night.
OK, it was a warm and sunny afternoon. But Halloween was approaching. Strange things happen. Plus, the patient’s name was Ichabod ...
OK, his name was Jerry. Jerry came to Boston from Chula Taco, Calif., to study at CIT, the famed Boston Chipotle Institute of Technology. He’d finished 4 months of isotretinoin and needed one more.
I asked him to call iPledge to request a transfer to me. He called back later to say that This seemed odd, since his pills had only run out 3 days before.
Having confirmed his name, address, telephone number, and the last four digits of his social security number, I tried enrolling him on iPledge at 5:30 p.m. (Cue: thunder and lightning), expecting to get a request for an override code. Instead the screen just asked for his iPledge number (you have to use the old one, you know). I called iPledge (my favorite pastime), identified myself by the usual means (Full name. iPledge ID number. Date of personal significance. Office telephone. Thank you. How can I help you?).
I explained my dilemma. The representative asked that I verify Jerry’s identity. I gave her his name, date of birth, and the last four of his social.
“We have his name and date of birth,” she said, “but the social security digits don’t match.” She asked for his phone number, but his Boston number didn’t match what she had. “Do you have his address?” she asked. I did not, since he’d given me his Boston address, not his California one.
I left her on hold and called Jerry on my cell. He confirmed that the social security digits he’d given me were correct. He gave me his mother’s cell phone number, but that also turned out not to be what iPledge had on file.
“What other identifying information can I give you?” I asked the iPledge rep. “How about his home address?” she said. Back to my cell: “Jerry, what’s your home address?” “It’s 2470 Chalupa Drive, Chula Taco, California 9090909-090909,” he said.
I repeated that to the iPledge representative. “Please hold a moment,” she said.
She was back. “The street address is correct,” she said, “The ZIP is correct. But the town is wrong.”
The town is wrong? If Jerry didn’t know either the last four of his social or his town, how did he get Amazon deliveries? Was this identity theft by an Accutane seeker? Maybe Jerry was really a Russian spy with dry lips posing as an acne patient! (Cue: screeches, howls, more thunder.)
“Can you tell me which town you have listed for him?” I asked iPledge.
“No,” she said, “because you haven’t identified him properly yet,” (emphasis added).
Back to the cell: “Jerry, are you sure you know what town you live in?” He insisted he did. (But then, so would a spy, wouldn’t he?)
In near despair, I returned to the iPledge rep. “I really want to get this patient his medication, “I said. “And I really want to go home. Can you help either of us?”
“Let me get my supervisor,” she said. “This may take a few minutes.” I hung up on Jerry and, in a blaze of multitasking, filled out three Prior Authorization forms for clindamycin gel.
“I found your patient,” said the rep, returning at last. “Not only that, I was able to reregister him in the iPledge program. Want to know his iPledge number?
Of course!
“Now that he’s registered,” I said, “could you give me the name of the town you have him listed as living in on Chalupa Drive?”
“Sure,” she said, “We have him in Rancho Carmen Miranda. Can help you with anything else today?”
“No, thanks ...”
“Would you be willing to take a 2-minute survey ...?”
“No, but thank you very much!” I said, hanging up in triumph. (Cue: sunshine, violins.)
Back to the cell: “Jerry, you’re in! Here’s your iPledge number.”
“Thanks, Doc.”
“By the way, Jerry, iPledge has you living in the town of Rancho Carmen Miranda. Do you live there?”
“No,” said Jerry. “I don’t.”
“Well, Jerry, for 1 more month, for federal purposes, you do!”
I’m sure there’s a good explanation for all this. I just don’t want to know it. Just pass the candy corn.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.