Alan Rockoff

Life always brings annoyances, major or otherwise. I'm no more peevish than usual; it's just that I've saved up a few smallish peeves, none weighty enough for a column of its own.

High-Tech Lists

It's an old story that lists are the bane of a dermatologist's life. I refer of course to the fellow who pulls out a used envelope or a slip of paper on which he's listed every spot he or his wife are concerned with or every skin-related question he's ever thought of but never had the chance to ask until, "Now that I've got you. …"

When the list is on a paper, you can gauge about how long it is and answer accordingly. You can also tell about how much farther you have to go.

Not so with people who whip out a handheld device, scroll to their list, and start to read. My heart sinks when I see that, because I have no idea how much longer this is going to go on, and when, or whether, I'll need to sue for mercy.

I suppose I could make up a waiting room sign that says, "Please Present All Question Lists to the Clerk for Encryption," but that might just encourage more people to make lists.

Warts Are Female, Skin Tags Are Male

That warts are female is clear; the original one is always called the mother wart. Skin tags (and seborrheic keratoses), however, are always male; every time and without exception, you will hear them called "little guys," as in, "Can't you get rid of these little guys?"

As a male, I find this disturbing. Females rightly complained when hurricanes were given only girls' names, which implied that women are windy, unpredictable, and sometimes destructive. Why then should men stand idly by while our gender is compared with things that just hang around being annoying, irritating, and redundant? Maybe Maureen Dowd of the New York Times can address this issue in the second edition of "Are Men Necessary?"

I Am Not a Dermo!

Internet correspondents have a habit of referring to members of our esteemed profession as "dermos" (as in, "I checked it out with my dermo").

We dermatologists are among the medical specialists favored with undignified monikers, like the ones that compare some physicians with creepy-crawlies ("orthopods"), gnarly mammals ("gynos"), or voodoo savants ("shrinks").

Not all specialists are so honored. Would you visit your interno? Consult your ophthalmo? Get a cysto from your uro?

Likewise, it's hard to imagine other professionals referred to in this way. Would anyone make a will with their attorno? Confess to their clergy guy? Prepare taxes with their bean counter? (There is, of course, "politico," but that's deserved.)

A variant of dermo is "derm." Even our professional publications sometimes call us that, running headlines like "Derms Tout Combo Tx," which makes it sound as though we're pushing a betting option at the dog track.

Clinical Research

From time to time, I'm asked to take part in drug evaluations. These may take the form of round-table discussions over dinner, in which I, a "thought leader," would be given the chance to air my leading thoughts about rosacea or eczema. Another option is to take part in clinical research, following a dozen or so patients to record how they fare with a particular product. Whether such "research" contributes to human knowledge or just advances brand-name recognition is another matter. In any case, I always decline these offers, though I'm tempted to accept just so I can add a financial disclaimer to my byline.

Then my eye falls on those ads on the inside front cover of prestigious periodicals like the New England Journal of Medicine, the ones for drugs that promise new hope for erectile dysfunction. Their copy includes footnoted claims like "high intercourse success," and "high patient satisfaction."

Now there's a research area of interest. The claims these adverstisements make raise important questions (methodologic, of course). For instance, how do they develop and validate questionnaires to assess "success" or "satisfaction?" And when, exactly, do they administer these questionnaires? These are matters in which I'm sure I could make a real—ad-writers would say affirmative—contribution. So how come no one ever asks me to?

RBRVS, CMS, OSHA, CLIA, HIPAA, HMO, PPO, PRO, ICD, CPT, iPLEDGE, ETC., ETC., ETC.

No elaboration needed.

Life always brings annoyances, major or otherwise. I'm no more peevish than usual; it's just that I've saved up a few smallish peeves, none weighty enough for a column of its own.

High-Tech Lists

It's an old story that lists are the bane of a dermatologist's life. I refer of course to the fellow who pulls out a used envelope or a slip of paper on which he's listed every spot he or his wife are concerned with or every skin-related question he's ever thought of but never had the chance to ask until, "Now that I've got you. …"

When the list is on a paper, you can gauge about how long it is and answer accordingly. You can also tell about how much farther you have to go.

Not so with people who whip out a handheld device, scroll to their list, and start to read. My heart sinks when I see that, because I have no idea how much longer this is going to go on, and when, or whether, I'll need to sue for mercy.

I suppose I could make up a waiting room sign that says, "Please Present All Question Lists to the Clerk for Encryption," but that might just encourage more people to make lists.

Warts Are Female, Skin Tags Are Male

That warts are female is clear; the original one is always called the mother wart. Skin tags (and seborrheic keratoses), however, are always male; every time and without exception, you will hear them called "little guys," as in, "Can't you get rid of these little guys?"

As a male, I find this disturbing. Females rightly complained when hurricanes were given only girls' names, which implied that women are windy, unpredictable, and sometimes destructive. Why then should men stand idly by while our gender is compared with things that just hang around being annoying, irritating, and redundant? Maybe Maureen Dowd of the New York Times can address this issue in the second edition of "Are Men Necessary?"

I Am Not a Dermo!

Internet correspondents have a habit of referring to members of our esteemed profession as "dermos" (as in, "I checked it out with my dermo").

We dermatologists are among the medical specialists favored with undignified monikers, like the ones that compare some physicians with creepy-crawlies ("orthopods"), gnarly mammals ("gynos"), or voodoo savants ("shrinks").

Not all specialists are so honored. Would you visit your interno? Consult your ophthalmo? Get a cysto from your uro?

Likewise, it's hard to imagine other professionals referred to in this way. Would anyone make a will with their attorno? Confess to their clergy guy? Prepare taxes with their bean counter? (There is, of course, "politico," but that's deserved.)

A variant of dermo is "derm." Even our professional publications sometimes call us that, running headlines like "Derms Tout Combo Tx," which makes it sound as though we're pushing a betting option at the dog track.

Clinical Research

From time to time, I'm asked to take part in drug evaluations. These may take the form of round-table discussions over dinner, in which I, a "thought leader," would be given the chance to air my leading thoughts about rosacea or eczema. Another option is to take part in clinical research, following a dozen or so patients to record how they fare with a particular product. Whether such "research" contributes to human knowledge or just advances brand-name recognition is another matter. In any case, I always decline these offers, though I'm tempted to accept just so I can add a financial disclaimer to my byline.

Then my eye falls on those ads on the inside front cover of prestigious periodicals like the New England Journal of Medicine, the ones for drugs that promise new hope for erectile dysfunction. Their copy includes footnoted claims like "high intercourse success," and "high patient satisfaction."

Now there's a research area of interest. The claims these adverstisements make raise important questions (methodologic, of course). For instance, how do they develop and validate questionnaires to assess "success" or "satisfaction?" And when, exactly, do they administer these questionnaires? These are matters in which I'm sure I could make a real—ad-writers would say affirmative—contribution. So how come no one ever asks me to?

RBRVS, CMS, OSHA, CLIA, HIPAA, HMO, PPO, PRO, ICD, CPT, iPLEDGE, ETC., ETC., ETC.

No elaboration needed.

Life always brings annoyances, major or otherwise. I'm no more peevish than usual; it's just that I've saved up a few smallish peeves, none weighty enough for a column of its own.

High-Tech Lists

It's an old story that lists are the bane of a dermatologist's life. I refer of course to the fellow who pulls out a used envelope or a slip of paper on which he's listed every spot he or his wife are concerned with or every skin-related question he's ever thought of but never had the chance to ask until, "Now that I've got you. …"

When the list is on a paper, you can gauge about how long it is and answer accordingly. You can also tell about how much farther you have to go.

Not so with people who whip out a handheld device, scroll to their list, and start to read. My heart sinks when I see that, because I have no idea how much longer this is going to go on, and when, or whether, I'll need to sue for mercy.

I suppose I could make up a waiting room sign that says, "Please Present All Question Lists to the Clerk for Encryption," but that might just encourage more people to make lists.

Warts Are Female, Skin Tags Are Male

That warts are female is clear; the original one is always called the mother wart. Skin tags (and seborrheic keratoses), however, are always male; every time and without exception, you will hear them called "little guys," as in, "Can't you get rid of these little guys?"

As a male, I find this disturbing. Females rightly complained when hurricanes were given only girls' names, which implied that women are windy, unpredictable, and sometimes destructive. Why then should men stand idly by while our gender is compared with things that just hang around being annoying, irritating, and redundant? Maybe Maureen Dowd of the New York Times can address this issue in the second edition of "Are Men Necessary?"

I Am Not a Dermo!

Internet correspondents have a habit of referring to members of our esteemed profession as "dermos" (as in, "I checked it out with my dermo").

We dermatologists are among the medical specialists favored with undignified monikers, like the ones that compare some physicians with creepy-crawlies ("orthopods"), gnarly mammals ("gynos"), or voodoo savants ("shrinks").

Not all specialists are so honored. Would you visit your interno? Consult your ophthalmo? Get a cysto from your uro?

Likewise, it's hard to imagine other professionals referred to in this way. Would anyone make a will with their attorno? Confess to their clergy guy? Prepare taxes with their bean counter? (There is, of course, "politico," but that's deserved.)

A variant of dermo is "derm." Even our professional publications sometimes call us that, running headlines like "Derms Tout Combo Tx," which makes it sound as though we're pushing a betting option at the dog track.

Clinical Research

From time to time, I'm asked to take part in drug evaluations. These may take the form of round-table discussions over dinner, in which I, a "thought leader," would be given the chance to air my leading thoughts about rosacea or eczema. Another option is to take part in clinical research, following a dozen or so patients to record how they fare with a particular product. Whether such "research" contributes to human knowledge or just advances brand-name recognition is another matter. In any case, I always decline these offers, though I'm tempted to accept just so I can add a financial disclaimer to my byline.

Then my eye falls on those ads on the inside front cover of prestigious periodicals like the New England Journal of Medicine, the ones for drugs that promise new hope for erectile dysfunction. Their copy includes footnoted claims like "high intercourse success," and "high patient satisfaction."

Now there's a research area of interest. The claims these adverstisements make raise important questions (methodologic, of course). For instance, how do they develop and validate questionnaires to assess "success" or "satisfaction?" And when, exactly, do they administer these questionnaires? These are matters in which I'm sure I could make a real—ad-writers would say affirmative—contribution. So how come no one ever asks me to?

RBRVS, CMS, OSHA, CLIA, HIPAA, HMO, PPO, PRO, ICD, CPT, iPLEDGE, ETC., ETC., ETC.

No elaboration needed.

In my last column, I suggested that it might be useful for the members of different specialties to discuss how each sees and does things. I had a recent chance to try this out myself when visiting the online Dermatology Forum (www.medhelp.org).

The issue that I raised was in relation to  molluscum contagiosum (MC). Often, molluscum doesn't act so contagiosum. Though MC is called an STD, many adults who get mollusca in the groin seem to have no contacts who have them, and kids, who tend to get it on the thorax, often don't either.

Below is one of the responses:

Dr. Handsfield (HHH) responds: I knew that someone would point out the differences between me and Dr. Rockoff about MC. The STD literature makes it clear that MC of the genital area in adults generally is sexually acquired. According to the main textbook on STDs, "The suspicion that genital MC is sexually transmitted is supported by lesion location, a frequent history of contact with multiple sexual partners, the presence of other STDs, genital lesions in sexual partners, and peak ages of occurrence (20–29 years) [as is the case for] other STDs."

Our differing perspectives might relate mostly to "genital area" infection. Many adults with MC involving other areas of the body may show up in a dermatology office and not STD clinics. Perhaps it is right that sex doesn't account for the majority of adult MC cases, but the case seems pretty clear for genital area infection.

That said, I'm sure there are exceptions—some genital and lower abdomen cases not sexually acquired. The main point is that such persons' sex partners should be examined, and people with genital MC should be routinely tested for other common STDs.

Dr. Rockoff (ASR) responds: I often have difficulty applying epidemiologic evidence to specific patients. Last Thursday, for instance, an 18-year-old boy came in with his father. He had two penile mollusca but denied ever having any sexual partners.

Today a 30-year-old with suprapubic mollusca told me he's had the same partner for 8 months, a woman with no genital lesions. I always ask, but men with pubic mollusca rarely tell me their partner has any, while men with warts often report a partner's HPV (human papillomavirus).

Patients may fib or just be wrong about their partners' status (though mollusca are easy enough to see when looked for). Still, telling an 18-year-old virgin that he has an STD is troubling. Likewise, saying this to a monogamous person raises questions of fidelity that perhaps needn't be raised. Failing to alert female partners of HPV exposure might lead to cervical cancer; less clear are the negative consequences of failing to detect a partner's molluscum.

If it's OK to admit that we have no idea why just one kid in the family gets MC on the thorax, why not say the same to an adult with groin lesions when there's nobody around to implicate?

I do agree that in adults with genital lesions, it's necessary to look into sexual history and contacts, as with any potential STD. In the MedHelp Forum, I'll make that clearer.

HHH responds: Thanks for your thoughtful comments. Clearly, sex doesn't explain all cases, and the difference in our perspectives obviously lies largely in which patients go where. People who show up in STD clinics obviously are biased in one direction; presumably those in private offices, the other way.

We also don't see many people who refer partners found to have MC, but it happens sometimes. Source partners are probably asymptomatic much of the time, especially women, who have greater anatomic opportunity for hidden lesions. Secondary (spread) contacts probably are mostly resistant/immune from their childhood infections.

MC might better be characterized not as a sexually transmitted disease but as a sexually transmissible one. Clearly, sex doesn't explain all cases. My main concern is that MC warrants at least asking patients about sexual risks and often screening them for common STDs. It may be confusing for MedHelp users to read overtly conflicting advice on different forums. For my part, I will pay more attention to terminology that leaves options open.

ASR responds: Thanks. And for my part, I'll emphasize the need to look into the possibility of sexual transmission and concurrent STDs. Your formulation, "not a sexually transmitted disease but a sexually transmissible one," seems just right.

One condition, two perspectives—the result of seeing somewhat different patient populations and of focusing on two aspects of the same problem: protecting the public health and addressing the individual patient. It can be helpful for each of us to see things the other's way.

In my last column, I suggested that it might be useful for the members of different specialties to discuss how each sees and does things. I had a recent chance to try this out myself when visiting the online Dermatology Forum (www.medhelp.org).

The issue that I raised was in relation to  molluscum contagiosum (MC). Often, molluscum doesn't act so contagiosum. Though MC is called an STD, many adults who get mollusca in the groin seem to have no contacts who have them, and kids, who tend to get it on the thorax, often don't either.

Below is one of the responses:

Dr. Handsfield (HHH) responds: I knew that someone would point out the differences between me and Dr. Rockoff about MC. The STD literature makes it clear that MC of the genital area in adults generally is sexually acquired. According to the main textbook on STDs, "The suspicion that genital MC is sexually transmitted is supported by lesion location, a frequent history of contact with multiple sexual partners, the presence of other STDs, genital lesions in sexual partners, and peak ages of occurrence (20–29 years) [as is the case for] other STDs."

Our differing perspectives might relate mostly to "genital area" infection. Many adults with MC involving other areas of the body may show up in a dermatology office and not STD clinics. Perhaps it is right that sex doesn't account for the majority of adult MC cases, but the case seems pretty clear for genital area infection.

That said, I'm sure there are exceptions—some genital and lower abdomen cases not sexually acquired. The main point is that such persons' sex partners should be examined, and people with genital MC should be routinely tested for other common STDs.

Dr. Rockoff (ASR) responds: I often have difficulty applying epidemiologic evidence to specific patients. Last Thursday, for instance, an 18-year-old boy came in with his father. He had two penile mollusca but denied ever having any sexual partners.

Today a 30-year-old with suprapubic mollusca told me he's had the same partner for 8 months, a woman with no genital lesions. I always ask, but men with pubic mollusca rarely tell me their partner has any, while men with warts often report a partner's HPV (human papillomavirus).

Patients may fib or just be wrong about their partners' status (though mollusca are easy enough to see when looked for). Still, telling an 18-year-old virgin that he has an STD is troubling. Likewise, saying this to a monogamous person raises questions of fidelity that perhaps needn't be raised. Failing to alert female partners of HPV exposure might lead to cervical cancer; less clear are the negative consequences of failing to detect a partner's molluscum.

If it's OK to admit that we have no idea why just one kid in the family gets MC on the thorax, why not say the same to an adult with groin lesions when there's nobody around to implicate?

I do agree that in adults with genital lesions, it's necessary to look into sexual history and contacts, as with any potential STD. In the MedHelp Forum, I'll make that clearer.

HHH responds: Thanks for your thoughtful comments. Clearly, sex doesn't explain all cases, and the difference in our perspectives obviously lies largely in which patients go where. People who show up in STD clinics obviously are biased in one direction; presumably those in private offices, the other way.

We also don't see many people who refer partners found to have MC, but it happens sometimes. Source partners are probably asymptomatic much of the time, especially women, who have greater anatomic opportunity for hidden lesions. Secondary (spread) contacts probably are mostly resistant/immune from their childhood infections.

MC might better be characterized not as a sexually transmitted disease but as a sexually transmissible one. Clearly, sex doesn't explain all cases. My main concern is that MC warrants at least asking patients about sexual risks and often screening them for common STDs. It may be confusing for MedHelp users to read overtly conflicting advice on different forums. For my part, I will pay more attention to terminology that leaves options open.

ASR responds: Thanks. And for my part, I'll emphasize the need to look into the possibility of sexual transmission and concurrent STDs. Your formulation, "not a sexually transmitted disease but a sexually transmissible one," seems just right.

One condition, two perspectives—the result of seeing somewhat different patient populations and of focusing on two aspects of the same problem: protecting the public health and addressing the individual patient. It can be helpful for each of us to see things the other's way.

In my last column, I suggested that it might be useful for the members of different specialties to discuss how each sees and does things. I had a recent chance to try this out myself when visiting the online Dermatology Forum (www.medhelp.org).

The issue that I raised was in relation to  molluscum contagiosum (MC). Often, molluscum doesn't act so contagiosum. Though MC is called an STD, many adults who get mollusca in the groin seem to have no contacts who have them, and kids, who tend to get it on the thorax, often don't either.

Below is one of the responses:

Dr. Handsfield (HHH) responds: I knew that someone would point out the differences between me and Dr. Rockoff about MC. The STD literature makes it clear that MC of the genital area in adults generally is sexually acquired. According to the main textbook on STDs, "The suspicion that genital MC is sexually transmitted is supported by lesion location, a frequent history of contact with multiple sexual partners, the presence of other STDs, genital lesions in sexual partners, and peak ages of occurrence (20–29 years) [as is the case for] other STDs."

Our differing perspectives might relate mostly to "genital area" infection. Many adults with MC involving other areas of the body may show up in a dermatology office and not STD clinics. Perhaps it is right that sex doesn't account for the majority of adult MC cases, but the case seems pretty clear for genital area infection.

That said, I'm sure there are exceptions—some genital and lower abdomen cases not sexually acquired. The main point is that such persons' sex partners should be examined, and people with genital MC should be routinely tested for other common STDs.

Dr. Rockoff (ASR) responds: I often have difficulty applying epidemiologic evidence to specific patients. Last Thursday, for instance, an 18-year-old boy came in with his father. He had two penile mollusca but denied ever having any sexual partners.

Today a 30-year-old with suprapubic mollusca told me he's had the same partner for 8 months, a woman with no genital lesions. I always ask, but men with pubic mollusca rarely tell me their partner has any, while men with warts often report a partner's HPV (human papillomavirus).

Patients may fib or just be wrong about their partners' status (though mollusca are easy enough to see when looked for). Still, telling an 18-year-old virgin that he has an STD is troubling. Likewise, saying this to a monogamous person raises questions of fidelity that perhaps needn't be raised. Failing to alert female partners of HPV exposure might lead to cervical cancer; less clear are the negative consequences of failing to detect a partner's molluscum.

If it's OK to admit that we have no idea why just one kid in the family gets MC on the thorax, why not say the same to an adult with groin lesions when there's nobody around to implicate?

I do agree that in adults with genital lesions, it's necessary to look into sexual history and contacts, as with any potential STD. In the MedHelp Forum, I'll make that clearer.

HHH responds: Thanks for your thoughtful comments. Clearly, sex doesn't explain all cases, and the difference in our perspectives obviously lies largely in which patients go where. People who show up in STD clinics obviously are biased in one direction; presumably those in private offices, the other way.

We also don't see many people who refer partners found to have MC, but it happens sometimes. Source partners are probably asymptomatic much of the time, especially women, who have greater anatomic opportunity for hidden lesions. Secondary (spread) contacts probably are mostly resistant/immune from their childhood infections.

MC might better be characterized not as a sexually transmitted disease but as a sexually transmissible one. Clearly, sex doesn't explain all cases. My main concern is that MC warrants at least asking patients about sexual risks and often screening them for common STDs. It may be confusing for MedHelp users to read overtly conflicting advice on different forums. For my part, I will pay more attention to terminology that leaves options open.

ASR responds: Thanks. And for my part, I'll emphasize the need to look into the possibility of sexual transmission and concurrent STDs. Your formulation, "not a sexually transmitted disease but a sexually transmissible one," seems just right.

One condition, two perspectives—the result of seeing somewhat different patient populations and of focusing on two aspects of the same problem: protecting the public health and addressing the individual patient. It can be helpful for each of us to see things the other's way.

Several years ago, a gynecologist came in to have me treat a wart. As I retrieved my can of LN2 spray, he asked, "Why do you use liquid nitrogen spray? Why not use a cryoprobe, the way we do?"

I felt like echoing Tevye in "Fiddler on the Roof" and saying: "So I'll tell you—I don't know. But it's a tradition."

LN₂ spray may indeed be the superior method, but nobody ever told me why. Truth be told, I use liquid nitrogen spray because I was trained to use it, my colleagues use it, and my specialty equipment catalogs feature it. I wouldn't even know where to order a cryoprobe. Liquid nitrogen is just what us derms do.

"What derms do" describes more of our techniques than we might care to admit. Once, a patient asked me, "For a strep throat, you take the same dose of antibiotic for the whole 10 days. How come when you treat acne, you lower the dose after a couple of months?"

That struck me as a good question, so I wrote to a former professor, widely known for acne expertise, and asked him whether there perhaps were data showing sustained antibiotic levels in sebum during maintenance, or something like that.

There weren't. The tapering technique, he explained, is traditional.

Other specialties have traditions too, about which we learn only incidentally. Each has its own professional society, its own standard journals, its own canonical texts, and, of course, its own treatment conditions. The opportunity to share—or critique—the way we each do things from an outside perspective rarely comes up.

What prompted these reflections was a recent chance I had to discuss a particular issue with an STD specialist. I'll defer the details of that conversation to the next column. Meantime, here is a random list of glimpses into treatment traditions from other specialists whose methods differ from ours in conditions we see every day:

▸ Pediatrics. During my pediatric residency, I learned very few things about skin, most of them wrong. One lesson I remember clearly: If a diaper rash involves the inguinal fold, it's always yeast. Well, it could be yeast. Then again, it could be the same kind of nonyeast rash that adults develop in intertriginous areas such as under arms or breasts.

▸ Family practice. I once got an FP throwaway journal with an article on "sweaty-sock dermatitis." The description and photos were of typical lichenified atopic dermatitis on the dorsal feet and toes. I wrote to the author to point this out. His reply was that, as far as family physicians were concerned, rashes like this are associated with sweaty socks.

▸ Ophthalmology. More and more patients without a single pimple or pustule come to me because their eye doctor told them they "have rosacea," based on an exam to evaluate dry eye. They've either started doxycycline or been referred to me to prescribe it. If I do, how will I know that it worked? And when will I stop? And why isn't there an ophthalmic metronidazole? Might be worth talking about all this with our ophthalmologist colleagues.

When it comes to blepharitis, ophthalmologists seem to reflexively recommend scrubbing the eyelids with baby shampoo. My dermatology sources don't even mention that method. It seems to be just something those eye docs do. Maybe we should too. Or maybe they shouldn't.

There are many other topics where interfield communication might be useful: with dentists about white oral lesions, with podiatrists about plantar warts, with surgeons about incisional biopsies. No doubt you can think of others.

I envision a comprehensive specialty parley, something like the United Nations, only less corrupt and dysfunctional. It might be more practical, though, to have a feature in each specialty journal called "Insights From Our Brethren." Finding out how other people do things could influence the way each of us goes about the business of training and practice.

Several years ago, a gynecologist came in to have me treat a wart. As I retrieved my can of LN2 spray, he asked, "Why do you use liquid nitrogen spray? Why not use a cryoprobe, the way we do?"

I felt like echoing Tevye in "Fiddler on the Roof" and saying: "So I'll tell you—I don't know. But it's a tradition."

LN₂ spray may indeed be the superior method, but nobody ever told me why. Truth be told, I use liquid nitrogen spray because I was trained to use it, my colleagues use it, and my specialty equipment catalogs feature it. I wouldn't even know where to order a cryoprobe. Liquid nitrogen is just what us derms do.

"What derms do" describes more of our techniques than we might care to admit. Once, a patient asked me, "For a strep throat, you take the same dose of antibiotic for the whole 10 days. How come when you treat acne, you lower the dose after a couple of months?"

That struck me as a good question, so I wrote to a former professor, widely known for acne expertise, and asked him whether there perhaps were data showing sustained antibiotic levels in sebum during maintenance, or something like that.

There weren't. The tapering technique, he explained, is traditional.

Other specialties have traditions too, about which we learn only incidentally. Each has its own professional society, its own standard journals, its own canonical texts, and, of course, its own treatment conditions. The opportunity to share—or critique—the way we each do things from an outside perspective rarely comes up.

What prompted these reflections was a recent chance I had to discuss a particular issue with an STD specialist. I'll defer the details of that conversation to the next column. Meantime, here is a random list of glimpses into treatment traditions from other specialists whose methods differ from ours in conditions we see every day:

▸ Pediatrics. During my pediatric residency, I learned very few things about skin, most of them wrong. One lesson I remember clearly: If a diaper rash involves the inguinal fold, it's always yeast. Well, it could be yeast. Then again, it could be the same kind of nonyeast rash that adults develop in intertriginous areas such as under arms or breasts.

▸ Family practice. I once got an FP throwaway journal with an article on "sweaty-sock dermatitis." The description and photos were of typical lichenified atopic dermatitis on the dorsal feet and toes. I wrote to the author to point this out. His reply was that, as far as family physicians were concerned, rashes like this are associated with sweaty socks.

▸ Ophthalmology. More and more patients without a single pimple or pustule come to me because their eye doctor told them they "have rosacea," based on an exam to evaluate dry eye. They've either started doxycycline or been referred to me to prescribe it. If I do, how will I know that it worked? And when will I stop? And why isn't there an ophthalmic metronidazole? Might be worth talking about all this with our ophthalmologist colleagues.

When it comes to blepharitis, ophthalmologists seem to reflexively recommend scrubbing the eyelids with baby shampoo. My dermatology sources don't even mention that method. It seems to be just something those eye docs do. Maybe we should too. Or maybe they shouldn't.

There are many other topics where interfield communication might be useful: with dentists about white oral lesions, with podiatrists about plantar warts, with surgeons about incisional biopsies. No doubt you can think of others.

I envision a comprehensive specialty parley, something like the United Nations, only less corrupt and dysfunctional. It might be more practical, though, to have a feature in each specialty journal called "Insights From Our Brethren." Finding out how other people do things could influence the way each of us goes about the business of training and practice.

Several years ago, a gynecologist came in to have me treat a wart. As I retrieved my can of LN2 spray, he asked, "Why do you use liquid nitrogen spray? Why not use a cryoprobe, the way we do?"

I felt like echoing Tevye in "Fiddler on the Roof" and saying: "So I'll tell you—I don't know. But it's a tradition."

LN₂ spray may indeed be the superior method, but nobody ever told me why. Truth be told, I use liquid nitrogen spray because I was trained to use it, my colleagues use it, and my specialty equipment catalogs feature it. I wouldn't even know where to order a cryoprobe. Liquid nitrogen is just what us derms do.

"What derms do" describes more of our techniques than we might care to admit. Once, a patient asked me, "For a strep throat, you take the same dose of antibiotic for the whole 10 days. How come when you treat acne, you lower the dose after a couple of months?"

That struck me as a good question, so I wrote to a former professor, widely known for acne expertise, and asked him whether there perhaps were data showing sustained antibiotic levels in sebum during maintenance, or something like that.

There weren't. The tapering technique, he explained, is traditional.

Other specialties have traditions too, about which we learn only incidentally. Each has its own professional society, its own standard journals, its own canonical texts, and, of course, its own treatment conditions. The opportunity to share—or critique—the way we each do things from an outside perspective rarely comes up.

What prompted these reflections was a recent chance I had to discuss a particular issue with an STD specialist. I'll defer the details of that conversation to the next column. Meantime, here is a random list of glimpses into treatment traditions from other specialists whose methods differ from ours in conditions we see every day:

▸ Pediatrics. During my pediatric residency, I learned very few things about skin, most of them wrong. One lesson I remember clearly: If a diaper rash involves the inguinal fold, it's always yeast. Well, it could be yeast. Then again, it could be the same kind of nonyeast rash that adults develop in intertriginous areas such as under arms or breasts.

▸ Family practice. I once got an FP throwaway journal with an article on "sweaty-sock dermatitis." The description and photos were of typical lichenified atopic dermatitis on the dorsal feet and toes. I wrote to the author to point this out. His reply was that, as far as family physicians were concerned, rashes like this are associated with sweaty socks.

▸ Ophthalmology. More and more patients without a single pimple or pustule come to me because their eye doctor told them they "have rosacea," based on an exam to evaluate dry eye. They've either started doxycycline or been referred to me to prescribe it. If I do, how will I know that it worked? And when will I stop? And why isn't there an ophthalmic metronidazole? Might be worth talking about all this with our ophthalmologist colleagues.

When it comes to blepharitis, ophthalmologists seem to reflexively recommend scrubbing the eyelids with baby shampoo. My dermatology sources don't even mention that method. It seems to be just something those eye docs do. Maybe we should too. Or maybe they shouldn't.

There are many other topics where interfield communication might be useful: with dentists about white oral lesions, with podiatrists about plantar warts, with surgeons about incisional biopsies. No doubt you can think of others.

I envision a comprehensive specialty parley, something like the United Nations, only less corrupt and dysfunctional. It might be more practical, though, to have a feature in each specialty journal called "Insights From Our Brethren." Finding out how other people do things could influence the way each of us goes about the business of training and practice.

"I've had this groin rash for weeks," says Harry. "Dr. Skimpole's tried different creams." Harry dumps tubes from a plastic bag onto his lap. The first is ketoconazole, the second fluocinonide, the third mupirocin.

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

Did Harry ask, "Gee, Doc, you gave me a fungus cream, then you switched to a steroid, and now it's an antibacterial. Do you have any idea what this is?" Harry did not ask.

I am constantly impressed, even amazed, at how often patients fail to ask doctors what we're doing and why. A college student has been on minocycline for 2 years, with no discernible effect. Has he asked his doctor, "Why are we staying with the same thing if it's not working?" He has not. Neither has his mother.

Of course, some people do ask. I don't mind explaining what I'm doing, and I often do so at length—until, not infrequently, I see the patient's eyes glaze over with the unspoken plea, "Could you please just give me the prescription so I can go?"

This lack of inquisitiveness crosses socioeconomic lines. College professors and working stiffs seem equally unlikely to challenge therapeutic decisions by asking doctors to explain and justify them. I use the word "challenge" advisedly.

If we were presenting on rounds, we would expect our attending physician to have us explain our treatment plan and to ask, "Why are you doing this, and how will it work?" When patients ask questions like these, they feel more like a challenge than a request for information: "So how do I know you know what you're doing, Doc?" Not many patients are aggressive enough to do that. Thank heavens.

We are trained to make the right diagnosis and prescribe the best treatment, based on the best available evidence. I am all for this and do it whenever possible. But in daily clinical life, the diagnosis is often unclear, treatment options are fuzzy, and evidence for efficacy is limited. The old maxim goes, "Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult."

This remains largely true—treatment algorithms, decision trees, HMO guideline report cards, and doctor-quality assessments notwithstanding.

It's a relief, then, when patients cut us slack and don't demand detailed explanations for many of the decisions we make. This comes in handy when we either don't have explanations or, for one reason or other, can't put them across.

I am not referring to high-stakes diagnostic and therapeutic challenges such as exotic diseases, medical mysteries, or excruciating end-of-life issues. Such situations generate learned musings on the dynamics and ethics of doctor-patient communication. The examples I have in mind are more homely, even trivial: the kinds of things, in other words, we deal with every day.

Consider Archie, a 3-year-old with infantile eczema. His mother insists that Archie "has been treated with everything" and that "nothing works." In this case, Archie has indeed been treated appropriately with a series of steroids and nonsteroids: hydrocortisone, desonide, pimecrolimus, and so forth. Because the diagnosis is clear, it seems reasonable to assume that what Mom means by "nothing is working" is that nothing has worked completely or fast enough or has prevented the rash from coming back elsewhere.

My own approach in such cases is to tell Mom, "I have a new and different cream that I'm convinced is just right for Archie." I ask that she apply it everywhere necessary twice a day, without fail, for 10 days and return. It works, of course, because she actually uses it long enough to see a result. Now she'll be better able to grasp the need for ongoing, intermittent treatment.

But what if she had asked me at the first visit: "I've already used a class 6 steroid, Doctor, and it says here on my Palm that the one you're giving me is just another class 6 steroid. What is the basis for predicting that your steroid will be more efficacious than the ones that have failed?"

Good question. To answer it, I would have to admit that the cream isn't objectively stronger, but she'll be more likely to stick with it because of my professional authority and calm reassurance. How would that go over?

Only she doesn't ask, not because she is uninterested or unintelligent, but because medical care is about more than patient autonomy and reportable outcomes. Among other things, it's about hope, fear, and trust.

Imagine dreaming that every day you have to justify every one of your clinical decisions to an attending or an administrator. Then picture waking up in a cold sweat, relieved that you're not in training anymore and that you still have some clinical independence.

Cherish it. It's shrinking.

"I've had this groin rash for weeks," says Harry. "Dr. Skimpole's tried different creams." Harry dumps tubes from a plastic bag onto his lap. The first is ketoconazole, the second fluocinonide, the third mupirocin.

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

Did Harry ask, "Gee, Doc, you gave me a fungus cream, then you switched to a steroid, and now it's an antibacterial. Do you have any idea what this is?" Harry did not ask.

I am constantly impressed, even amazed, at how often patients fail to ask doctors what we're doing and why. A college student has been on minocycline for 2 years, with no discernible effect. Has he asked his doctor, "Why are we staying with the same thing if it's not working?" He has not. Neither has his mother.

Of course, some people do ask. I don't mind explaining what I'm doing, and I often do so at length—until, not infrequently, I see the patient's eyes glaze over with the unspoken plea, "Could you please just give me the prescription so I can go?"

This lack of inquisitiveness crosses socioeconomic lines. College professors and working stiffs seem equally unlikely to challenge therapeutic decisions by asking doctors to explain and justify them. I use the word "challenge" advisedly.

If we were presenting on rounds, we would expect our attending physician to have us explain our treatment plan and to ask, "Why are you doing this, and how will it work?" When patients ask questions like these, they feel more like a challenge than a request for information: "So how do I know you know what you're doing, Doc?" Not many patients are aggressive enough to do that. Thank heavens.

We are trained to make the right diagnosis and prescribe the best treatment, based on the best available evidence. I am all for this and do it whenever possible. But in daily clinical life, the diagnosis is often unclear, treatment options are fuzzy, and evidence for efficacy is limited. The old maxim goes, "Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult."

This remains largely true—treatment algorithms, decision trees, HMO guideline report cards, and doctor-quality assessments notwithstanding.

It's a relief, then, when patients cut us slack and don't demand detailed explanations for many of the decisions we make. This comes in handy when we either don't have explanations or, for one reason or other, can't put them across.

I am not referring to high-stakes diagnostic and therapeutic challenges such as exotic diseases, medical mysteries, or excruciating end-of-life issues. Such situations generate learned musings on the dynamics and ethics of doctor-patient communication. The examples I have in mind are more homely, even trivial: the kinds of things, in other words, we deal with every day.

Consider Archie, a 3-year-old with infantile eczema. His mother insists that Archie "has been treated with everything" and that "nothing works." In this case, Archie has indeed been treated appropriately with a series of steroids and nonsteroids: hydrocortisone, desonide, pimecrolimus, and so forth. Because the diagnosis is clear, it seems reasonable to assume that what Mom means by "nothing is working" is that nothing has worked completely or fast enough or has prevented the rash from coming back elsewhere.

My own approach in such cases is to tell Mom, "I have a new and different cream that I'm convinced is just right for Archie." I ask that she apply it everywhere necessary twice a day, without fail, for 10 days and return. It works, of course, because she actually uses it long enough to see a result. Now she'll be better able to grasp the need for ongoing, intermittent treatment.

But what if she had asked me at the first visit: "I've already used a class 6 steroid, Doctor, and it says here on my Palm that the one you're giving me is just another class 6 steroid. What is the basis for predicting that your steroid will be more efficacious than the ones that have failed?"

Good question. To answer it, I would have to admit that the cream isn't objectively stronger, but she'll be more likely to stick with it because of my professional authority and calm reassurance. How would that go over?

Only she doesn't ask, not because she is uninterested or unintelligent, but because medical care is about more than patient autonomy and reportable outcomes. Among other things, it's about hope, fear, and trust.

Imagine dreaming that every day you have to justify every one of your clinical decisions to an attending or an administrator. Then picture waking up in a cold sweat, relieved that you're not in training anymore and that you still have some clinical independence.

Cherish it. It's shrinking.

"I've had this groin rash for weeks," says Harry. "Dr. Skimpole's tried different creams." Harry dumps tubes from a plastic bag onto his lap. The first is ketoconazole, the second fluocinonide, the third mupirocin.

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

Did Harry ask, "Gee, Doc, you gave me a fungus cream, then you switched to a steroid, and now it's an antibacterial. Do you have any idea what this is?" Harry did not ask.

I am constantly impressed, even amazed, at how often patients fail to ask doctors what we're doing and why. A college student has been on minocycline for 2 years, with no discernible effect. Has he asked his doctor, "Why are we staying with the same thing if it's not working?" He has not. Neither has his mother.

Of course, some people do ask. I don't mind explaining what I'm doing, and I often do so at length—until, not infrequently, I see the patient's eyes glaze over with the unspoken plea, "Could you please just give me the prescription so I can go?"

This lack of inquisitiveness crosses socioeconomic lines. College professors and working stiffs seem equally unlikely to challenge therapeutic decisions by asking doctors to explain and justify them. I use the word "challenge" advisedly.

If we were presenting on rounds, we would expect our attending physician to have us explain our treatment plan and to ask, "Why are you doing this, and how will it work?" When patients ask questions like these, they feel more like a challenge than a request for information: "So how do I know you know what you're doing, Doc?" Not many patients are aggressive enough to do that. Thank heavens.

We are trained to make the right diagnosis and prescribe the best treatment, based on the best available evidence. I am all for this and do it whenever possible. But in daily clinical life, the diagnosis is often unclear, treatment options are fuzzy, and evidence for efficacy is limited. The old maxim goes, "Life is short, the art long, opportunity fleeting, experience treacherous, judgment difficult."

This remains largely true—treatment algorithms, decision trees, HMO guideline report cards, and doctor-quality assessments notwithstanding.

It's a relief, then, when patients cut us slack and don't demand detailed explanations for many of the decisions we make. This comes in handy when we either don't have explanations or, for one reason or other, can't put them across.

I am not referring to high-stakes diagnostic and therapeutic challenges such as exotic diseases, medical mysteries, or excruciating end-of-life issues. Such situations generate learned musings on the dynamics and ethics of doctor-patient communication. The examples I have in mind are more homely, even trivial: the kinds of things, in other words, we deal with every day.

Consider Archie, a 3-year-old with infantile eczema. His mother insists that Archie "has been treated with everything" and that "nothing works." In this case, Archie has indeed been treated appropriately with a series of steroids and nonsteroids: hydrocortisone, desonide, pimecrolimus, and so forth. Because the diagnosis is clear, it seems reasonable to assume that what Mom means by "nothing is working" is that nothing has worked completely or fast enough or has prevented the rash from coming back elsewhere.

My own approach in such cases is to tell Mom, "I have a new and different cream that I'm convinced is just right for Archie." I ask that she apply it everywhere necessary twice a day, without fail, for 10 days and return. It works, of course, because she actually uses it long enough to see a result. Now she'll be better able to grasp the need for ongoing, intermittent treatment.

But what if she had asked me at the first visit: "I've already used a class 6 steroid, Doctor, and it says here on my Palm that the one you're giving me is just another class 6 steroid. What is the basis for predicting that your steroid will be more efficacious than the ones that have failed?"

Good question. To answer it, I would have to admit that the cream isn't objectively stronger, but she'll be more likely to stick with it because of my professional authority and calm reassurance. How would that go over?

Only she doesn't ask, not because she is uninterested or unintelligent, but because medical care is about more than patient autonomy and reportable outcomes. Among other things, it's about hope, fear, and trust.

Imagine dreaming that every day you have to justify every one of your clinical decisions to an attending or an administrator. Then picture waking up in a cold sweat, relieved that you're not in training anymore and that you still have some clinical independence.

Cherish it. It's shrinking.

"But nobody in my family has it!"

That's a common reaction patients have when told their condition is hereditary.

Saying a disease is genetic gives the patient more than just a point of information. Heredity is one of the "Big Seven," the ways people explain illness to themselves and make its appearance feel more plausible and less like a bolt from the blue: heredity, diet, environment ("the air," "the water"), allergy, infection, cancer, and aging (which explains almost anything—"When you get old, everything happens"). Calling something hereditary helps it make sense, which is useful.

What people mean by hereditary (they call it "taking after") is not the same as what we mean by genetics, although the two concepts overlap somewhat. Patients think of genetics in a global sense: If you look like someone, have the same skin type, or otherwise resemble a forebear somehow, then you're considered likely to get what they had and unlikely to get what they didn't. People are always saying things like, "I inherited my Dad's fair skin, but my sister is dark like my mother." Genetics is a bit more complex than that, of course. Besides, the alleged resemblance is supposed to explain not just being prone to skin cancer—which sounds semireasonable—but being vulnerable to lots of other diseases that have nothing to do with UV tolerance.

People also tend to think that if someone they take after had a problem to a certain extent, then they too will suffer the same way. Psoriasis does indeed have a genetic component, but onset, duration, and severity hardly follow set familial patterns.

To further complicate matters, family mythology about what so-and-so had and how bad it was may be imprecise, to say the least. Think of statements like, "My aunt had a dozen melanomas."

In addition, people assign genetics to specific things in a way we physicians never would. Many insist that their mother/sister/aunt had "the same mole" as the one we're examining or planning to biopsy. What does the same mole mean? That it occupied the same exact anatomical place? How would they know? And what difference would it make? Yet, to the patient this designation makes good sense, implying a commonality of medical fate, for good or ill, with their similarly moled relative.

So when a 40-year-old shows up with atopic dermatitis, she's going to consider it mighty unlikely that it "just came" for no reason. (She "didn't change anything," "did not eat anything different," and so forth.) Explaining that eczema is hereditary makes its arrival more reasonable to her, without the need to blame something she did or ate.

That is, if you can convince her when she claims "nobody in the family has it!" There are several reasons patients may not know any relatives with the condition:

▸ Actually, nobody does have it. Not every hereditary condition affects every family member.

▸ They would have had it if they'd lived long enough. Seborrheic keratoses, for instance.

▸ They do have it but never told you. Imagine a Thanksgiving dinner: "So how's it going, Uncle Ebenezer?" "Pretty tolerable, Clem. But those pesky skin tags in my groin've been acting up again. Got 'em from Ma."

▸ They do have it, but nobody told them. How many patients with atopic dermatitis go through life thinking or being told that they have "dry skin" or "allergies"?

Specifying genetics can have negative effects, too. Even modern folks may not be free of the guilt associated with "passing something on." Rationally, no one should feel guilty for having a gene someone gave him or her. But guilt is not rational.

Perhaps some day the Human Genome Project will provide us with a more precise and detailed understanding of what gets passed on and how. Even then, however, it will still be true that you can pick your friends …

You know the rest.

"But nobody in my family has it!"

That's a common reaction patients have when told their condition is hereditary.

Saying a disease is genetic gives the patient more than just a point of information. Heredity is one of the "Big Seven," the ways people explain illness to themselves and make its appearance feel more plausible and less like a bolt from the blue: heredity, diet, environment ("the air," "the water"), allergy, infection, cancer, and aging (which explains almost anything—"When you get old, everything happens"). Calling something hereditary helps it make sense, which is useful.

What people mean by hereditary (they call it "taking after") is not the same as what we mean by genetics, although the two concepts overlap somewhat. Patients think of genetics in a global sense: If you look like someone, have the same skin type, or otherwise resemble a forebear somehow, then you're considered likely to get what they had and unlikely to get what they didn't. People are always saying things like, "I inherited my Dad's fair skin, but my sister is dark like my mother." Genetics is a bit more complex than that, of course. Besides, the alleged resemblance is supposed to explain not just being prone to skin cancer—which sounds semireasonable—but being vulnerable to lots of other diseases that have nothing to do with UV tolerance.

People also tend to think that if someone they take after had a problem to a certain extent, then they too will suffer the same way. Psoriasis does indeed have a genetic component, but onset, duration, and severity hardly follow set familial patterns.

To further complicate matters, family mythology about what so-and-so had and how bad it was may be imprecise, to say the least. Think of statements like, "My aunt had a dozen melanomas."

In addition, people assign genetics to specific things in a way we physicians never would. Many insist that their mother/sister/aunt had "the same mole" as the one we're examining or planning to biopsy. What does the same mole mean? That it occupied the same exact anatomical place? How would they know? And what difference would it make? Yet, to the patient this designation makes good sense, implying a commonality of medical fate, for good or ill, with their similarly moled relative.

So when a 40-year-old shows up with atopic dermatitis, she's going to consider it mighty unlikely that it "just came" for no reason. (She "didn't change anything," "did not eat anything different," and so forth.) Explaining that eczema is hereditary makes its arrival more reasonable to her, without the need to blame something she did or ate.

That is, if you can convince her when she claims "nobody in the family has it!" There are several reasons patients may not know any relatives with the condition:

▸ Actually, nobody does have it. Not every hereditary condition affects every family member.

▸ They would have had it if they'd lived long enough. Seborrheic keratoses, for instance.

▸ They do have it but never told you. Imagine a Thanksgiving dinner: "So how's it going, Uncle Ebenezer?" "Pretty tolerable, Clem. But those pesky skin tags in my groin've been acting up again. Got 'em from Ma."

▸ They do have it, but nobody told them. How many patients with atopic dermatitis go through life thinking or being told that they have "dry skin" or "allergies"?

Specifying genetics can have negative effects, too. Even modern folks may not be free of the guilt associated with "passing something on." Rationally, no one should feel guilty for having a gene someone gave him or her. But guilt is not rational.

Perhaps some day the Human Genome Project will provide us with a more precise and detailed understanding of what gets passed on and how. Even then, however, it will still be true that you can pick your friends …

You know the rest.

"But nobody in my family has it!"

That's a common reaction patients have when told their condition is hereditary.

Saying a disease is genetic gives the patient more than just a point of information. Heredity is one of the "Big Seven," the ways people explain illness to themselves and make its appearance feel more plausible and less like a bolt from the blue: heredity, diet, environment ("the air," "the water"), allergy, infection, cancer, and aging (which explains almost anything—"When you get old, everything happens"). Calling something hereditary helps it make sense, which is useful.

What people mean by hereditary (they call it "taking after") is not the same as what we mean by genetics, although the two concepts overlap somewhat. Patients think of genetics in a global sense: If you look like someone, have the same skin type, or otherwise resemble a forebear somehow, then you're considered likely to get what they had and unlikely to get what they didn't. People are always saying things like, "I inherited my Dad's fair skin, but my sister is dark like my mother." Genetics is a bit more complex than that, of course. Besides, the alleged resemblance is supposed to explain not just being prone to skin cancer—which sounds semireasonable—but being vulnerable to lots of other diseases that have nothing to do with UV tolerance.

People also tend to think that if someone they take after had a problem to a certain extent, then they too will suffer the same way. Psoriasis does indeed have a genetic component, but onset, duration, and severity hardly follow set familial patterns.

To further complicate matters, family mythology about what so-and-so had and how bad it was may be imprecise, to say the least. Think of statements like, "My aunt had a dozen melanomas."

In addition, people assign genetics to specific things in a way we physicians never would. Many insist that their mother/sister/aunt had "the same mole" as the one we're examining or planning to biopsy. What does the same mole mean? That it occupied the same exact anatomical place? How would they know? And what difference would it make? Yet, to the patient this designation makes good sense, implying a commonality of medical fate, for good or ill, with their similarly moled relative.

So when a 40-year-old shows up with atopic dermatitis, she's going to consider it mighty unlikely that it "just came" for no reason. (She "didn't change anything," "did not eat anything different," and so forth.) Explaining that eczema is hereditary makes its arrival more reasonable to her, without the need to blame something she did or ate.

That is, if you can convince her when she claims "nobody in the family has it!" There are several reasons patients may not know any relatives with the condition:

▸ Actually, nobody does have it. Not every hereditary condition affects every family member.

▸ They would have had it if they'd lived long enough. Seborrheic keratoses, for instance.

▸ They do have it but never told you. Imagine a Thanksgiving dinner: "So how's it going, Uncle Ebenezer?" "Pretty tolerable, Clem. But those pesky skin tags in my groin've been acting up again. Got 'em from Ma."

▸ They do have it, but nobody told them. How many patients with atopic dermatitis go through life thinking or being told that they have "dry skin" or "allergies"?

Specifying genetics can have negative effects, too. Even modern folks may not be free of the guilt associated with "passing something on." Rationally, no one should feel guilty for having a gene someone gave him or her. But guilt is not rational.

Perhaps some day the Human Genome Project will provide us with a more precise and detailed understanding of what gets passed on and how. Even then, however, it will still be true that you can pick your friends …

You know the rest.

I was flattered.

Vladimir had brought in his eczematous infant for a second opinion. No doubt he chose me because his GP was unsure and he'd heard I'm boarded in pediatrics. Not exactly.

In fact, he had already consulted a well-known pediatric dermatologist. "I was waiting for the commuter train in Sharon," said Vladimir, "I met this Russian guy and asked him if he knew a good dermatologist."

It's nice to hear that some Russian commuter thinks I'm good. But how does he know? And what is a good doctor, anyway?

This is not an idle question. Pay for performance is our Next Big Thing. HMOs now reward hospitals for practicing better medicine. Prodded by Medicare, professional associations are developing quality guidelines. Soon enough, patients will get lower copays for consulting better doctors.

OK, what's a better doctor?

This question is too complex for me to address in depth. I've observed, however, how hard it is to judge physician quality even when we want to, such as when referring patients to Mohs surgeons, internists, ophthalmologists, allergists, etc.

When people are referred to me, they often say things like, "Dr. Smith says you're terrific!" Since I've only seen a handful of Dr. Smith's patients and never met him, how does he know I'm terrific? Can he gauge my diagnostic acumen? Does he know my outcome data?

When I refer, I also say my colleague is swell; I want the patient to feel confident. Although I really believe the doctor is good, critical assessment forces me to concede that my evidence is thin. What, after all, do I really know about this doctor?

▸ Patients say his staff is nice.

▸ She sends prompt referral letters.

▸ He'll see an emergency right away.

▸ I once met her in the hall, and she seemed personable.

Such criteria imply something about my colleagues' characters and managerial skills but not much about competence. Is the internist a sharp diagnostician? Would she nail kala-azar if it came her way? How would I know? Because the people I send her mostly need routine physicals, does it matter? I guess the Mohs guy has good technique—he sends pictures of gaping wounds and neat stitching. But is he better or worse than anybody else? I must admit I'm in no position to judge.

If doctors aren't too clever at recognizing quality, patients are perhaps worse. At times, most of us learn about truly terrible physicians who miss basic diagnoses, treat patients with casual contempt, do surgery beyond their ability, or biopsy anything that moves. They're still in practice because most of their patients are still breathing. And many of these doctors have one striking thing in common:

They are wildly successful. Their patients swear by them.

In other pursuits, gauging quality is fairly straightforward: gardening, auto repair, taxidermy. Defining excellence in medical care is a bit subtler, for reasons too numerous to list. Soon, however, we're going to have to do it anyway, because those who pay our bills want value for their money. And they say value means "quality care."

So they've started with dramatic procedures with easily measured outcomes, like mortality rates for transplants. For the rest of us, they want process data: how often doctors measure hemoglobin A_1c in people with diabetes or prescribe steroid inhalers to asthma patients, and so on. Good process may turn out to produce good outcome, or it may not. Either way, we're going to have to both do the right thing and—most crucial—report that we did it. If we don't, the counters will be displeased and our efforts won't count.

Will this make us better doctors? Consider: Everyone agrees that a good doctor assesses whether isotretinoin patients understand precautions. The iPLEDGE program forces us to click the box, "In my opinion, this patient understands and is capable of complying with the requirements of the iPLEDGE program." Does forcing us to click this box make us better?

Years of struggle with PCP referrals, OSHA, CLIA, and E/M codes make one realize the futility of debating bureaucratic imperatives. Soon we'll have more boxes to click, along with online physician-quality tables for patients to peruse.

But many will still find their way to excellence the old-fashioned way.

Like Eddie, who has a rare and debilitating neuropathy. "I'm seeing Dr. Lariat over at St. Anselm's," he says.

"I hear he's tops," I reply. "How'd you find him?"

"Funny," says Eddie. "My brother-in-law Dave has box seats at Fenway. Turns out that the guy in the next box is a neurologist at MBH. When Dave tells him what I've got, the guy says, 'Neuropathy? He's gotta see Lariat over at St. Anselm's. He's the best!'"

I was flattered.

Vladimir had brought in his eczematous infant for a second opinion. No doubt he chose me because his GP was unsure and he'd heard I'm boarded in pediatrics. Not exactly.

In fact, he had already consulted a well-known pediatric dermatologist. "I was waiting for the commuter train in Sharon," said Vladimir, "I met this Russian guy and asked him if he knew a good dermatologist."

It's nice to hear that some Russian commuter thinks I'm good. But how does he know? And what is a good doctor, anyway?

This is not an idle question. Pay for performance is our Next Big Thing. HMOs now reward hospitals for practicing better medicine. Prodded by Medicare, professional associations are developing quality guidelines. Soon enough, patients will get lower copays for consulting better doctors.

OK, what's a better doctor?

This question is too complex for me to address in depth. I've observed, however, how hard it is to judge physician quality even when we want to, such as when referring patients to Mohs surgeons, internists, ophthalmologists, allergists, etc.

When people are referred to me, they often say things like, "Dr. Smith says you're terrific!" Since I've only seen a handful of Dr. Smith's patients and never met him, how does he know I'm terrific? Can he gauge my diagnostic acumen? Does he know my outcome data?

When I refer, I also say my colleague is swell; I want the patient to feel confident. Although I really believe the doctor is good, critical assessment forces me to concede that my evidence is thin. What, after all, do I really know about this doctor?

▸ Patients say his staff is nice.

▸ She sends prompt referral letters.

▸ He'll see an emergency right away.

▸ I once met her in the hall, and she seemed personable.

Such criteria imply something about my colleagues' characters and managerial skills but not much about competence. Is the internist a sharp diagnostician? Would she nail kala-azar if it came her way? How would I know? Because the people I send her mostly need routine physicals, does it matter? I guess the Mohs guy has good technique—he sends pictures of gaping wounds and neat stitching. But is he better or worse than anybody else? I must admit I'm in no position to judge.

If doctors aren't too clever at recognizing quality, patients are perhaps worse. At times, most of us learn about truly terrible physicians who miss basic diagnoses, treat patients with casual contempt, do surgery beyond their ability, or biopsy anything that moves. They're still in practice because most of their patients are still breathing. And many of these doctors have one striking thing in common:

They are wildly successful. Their patients swear by them.

In other pursuits, gauging quality is fairly straightforward: gardening, auto repair, taxidermy. Defining excellence in medical care is a bit subtler, for reasons too numerous to list. Soon, however, we're going to have to do it anyway, because those who pay our bills want value for their money. And they say value means "quality care."

So they've started with dramatic procedures with easily measured outcomes, like mortality rates for transplants. For the rest of us, they want process data: how often doctors measure hemoglobin A_1c in people with diabetes or prescribe steroid inhalers to asthma patients, and so on. Good process may turn out to produce good outcome, or it may not. Either way, we're going to have to both do the right thing and—most crucial—report that we did it. If we don't, the counters will be displeased and our efforts won't count.

Will this make us better doctors? Consider: Everyone agrees that a good doctor assesses whether isotretinoin patients understand precautions. The iPLEDGE program forces us to click the box, "In my opinion, this patient understands and is capable of complying with the requirements of the iPLEDGE program." Does forcing us to click this box make us better?

Years of struggle with PCP referrals, OSHA, CLIA, and E/M codes make one realize the futility of debating bureaucratic imperatives. Soon we'll have more boxes to click, along with online physician-quality tables for patients to peruse.

But many will still find their way to excellence the old-fashioned way.

Like Eddie, who has a rare and debilitating neuropathy. "I'm seeing Dr. Lariat over at St. Anselm's," he says.

"I hear he's tops," I reply. "How'd you find him?"

"Funny," says Eddie. "My brother-in-law Dave has box seats at Fenway. Turns out that the guy in the next box is a neurologist at MBH. When Dave tells him what I've got, the guy says, 'Neuropathy? He's gotta see Lariat over at St. Anselm's. He's the best!'"

I was flattered.

Vladimir had brought in his eczematous infant for a second opinion. No doubt he chose me because his GP was unsure and he'd heard I'm boarded in pediatrics. Not exactly.

In fact, he had already consulted a well-known pediatric dermatologist. "I was waiting for the commuter train in Sharon," said Vladimir, "I met this Russian guy and asked him if he knew a good dermatologist."

It's nice to hear that some Russian commuter thinks I'm good. But how does he know? And what is a good doctor, anyway?

This is not an idle question. Pay for performance is our Next Big Thing. HMOs now reward hospitals for practicing better medicine. Prodded by Medicare, professional associations are developing quality guidelines. Soon enough, patients will get lower copays for consulting better doctors.

OK, what's a better doctor?

This question is too complex for me to address in depth. I've observed, however, how hard it is to judge physician quality even when we want to, such as when referring patients to Mohs surgeons, internists, ophthalmologists, allergists, etc.

When people are referred to me, they often say things like, "Dr. Smith says you're terrific!" Since I've only seen a handful of Dr. Smith's patients and never met him, how does he know I'm terrific? Can he gauge my diagnostic acumen? Does he know my outcome data?

When I refer, I also say my colleague is swell; I want the patient to feel confident. Although I really believe the doctor is good, critical assessment forces me to concede that my evidence is thin. What, after all, do I really know about this doctor?

▸ Patients say his staff is nice.

▸ She sends prompt referral letters.

▸ He'll see an emergency right away.

▸ I once met her in the hall, and she seemed personable.

Such criteria imply something about my colleagues' characters and managerial skills but not much about competence. Is the internist a sharp diagnostician? Would she nail kala-azar if it came her way? How would I know? Because the people I send her mostly need routine physicals, does it matter? I guess the Mohs guy has good technique—he sends pictures of gaping wounds and neat stitching. But is he better or worse than anybody else? I must admit I'm in no position to judge.

If doctors aren't too clever at recognizing quality, patients are perhaps worse. At times, most of us learn about truly terrible physicians who miss basic diagnoses, treat patients with casual contempt, do surgery beyond their ability, or biopsy anything that moves. They're still in practice because most of their patients are still breathing. And many of these doctors have one striking thing in common:

They are wildly successful. Their patients swear by them.

In other pursuits, gauging quality is fairly straightforward: gardening, auto repair, taxidermy. Defining excellence in medical care is a bit subtler, for reasons too numerous to list. Soon, however, we're going to have to do it anyway, because those who pay our bills want value for their money. And they say value means "quality care."

So they've started with dramatic procedures with easily measured outcomes, like mortality rates for transplants. For the rest of us, they want process data: how often doctors measure hemoglobin A_1c in people with diabetes or prescribe steroid inhalers to asthma patients, and so on. Good process may turn out to produce good outcome, or it may not. Either way, we're going to have to both do the right thing and—most crucial—report that we did it. If we don't, the counters will be displeased and our efforts won't count.

Will this make us better doctors? Consider: Everyone agrees that a good doctor assesses whether isotretinoin patients understand precautions. The iPLEDGE program forces us to click the box, "In my opinion, this patient understands and is capable of complying with the requirements of the iPLEDGE program." Does forcing us to click this box make us better?

Years of struggle with PCP referrals, OSHA, CLIA, and E/M codes make one realize the futility of debating bureaucratic imperatives. Soon we'll have more boxes to click, along with online physician-quality tables for patients to peruse.

But many will still find their way to excellence the old-fashioned way.

Like Eddie, who has a rare and debilitating neuropathy. "I'm seeing Dr. Lariat over at St. Anselm's," he says.

"I hear he's tops," I reply. "How'd you find him?"

"Funny," says Eddie. "My brother-in-law Dave has box seats at Fenway. Turns out that the guy in the next box is a neurologist at MBH. When Dave tells him what I've got, the guy says, 'Neuropathy? He's gotta see Lariat over at St. Anselm's. He's the best!'"

Good morning, Mr. Nesia. I see you haven't been here in 15 years."

"I was never here before."

"Forgive me—aren't you Alford M. Nesia, address 36 Endive Gardens Avenue, Boxboro, date of birth April 5, 1954?"

"Yes."

"In that case, you were here in August of 1991."

"I did see a dermatologist once, come to think of it. Was that you?"

It's always nice to know you've made a strong impression. Of course, forgetfulness works both ways:

"Nice to meet you, Ms. Jones."

"I saw you last month, Doctor."

Ouch. This usually happens when my staff checks in an old patient as a new one. Sometimes they haven't been able to find the patient's name in the computer (misspellings, data loss, a 20-year absence, whatever). In other cases, the patient has come in with a child or other relative but never registered under his or her own name. I have a pretty good memory, but without a chart, I'm mostly lost.

Unrecognized patients often make allowances. "You have so many patients, Doctor, you can't possibly remember them all." True enough.

I do try, though. People are often flattered when recognized, offended when they're not. (That's why politicians make such a point of remembering everyone.) Knowing who people are is a good start, but recollecting personal details is even better. I often note such details in the chart, whether they're germane to skin complaints or not. The patient may have started a new job, graduated college, bought a condo, planned a honeymoon in Uzbekistan.

When notes jog my memory about such things, I deftly slip in a personal reference while writing a prescription. "The doxycycline is refillable three times, Ned. By the way, how was the bridal suite at the Samarkand Motel 6?"

If the patient exclaims, "You have a good memory! How did you remember that?" I usually confess that I'd written it down. That doesn't seem to offend anybody; instead, they're somewhat pleased to have a stranger show some interest in their nonmedical lives. I do it to make people comfortable and to get to know them a bit, because many of them come back at odd intervals over the course of many years.

I have another reason, too—a dark secret now revealed here for the first time: I occasionally find patients' stories even more riveting than the diagnostic and therapeutic challenges posed by their rashes and skin growths. There, I said it.

Outside the office, I'm even more lost when greeted by patients who know me. By now, I've been around long enough that it's hard to go to the grocery or the gym or to just walk down the street without running into someone who stares, grins, and says, "Dr. Rockoff—is that you?"

I usually admit that it is and smile brightly in apparent recognition, keeping a keen eye out for an escape route before further conversation can unmask my ignorance of who the dickens they are. ("You know me! The one with the rash!") My father, well known in our hometown, was often hailed by strangers. He always smiled heartily and waved back. "Who was that?" I'd ask. "I have no idea," he'd say. "But they seem to know me, so I wave."

Of course, it's hard to recognize people out of context. I think my patients should have an easier time remembering me than I do them; after all, there are so many of them and just one of me. For the most part that's true, but some folks are just better at remembering than others are.

"Nice to meet you, Mr. Steele."

"I met you already."

"Well, actually, the one time you were here before, you saw my associate Henrietta."

"You know, you're right—it was a lady!"

Glad we straightened that out.

Good morning, Mr. Nesia. I see you haven't been here in 15 years."

"I was never here before."

"Forgive me—aren't you Alford M. Nesia, address 36 Endive Gardens Avenue, Boxboro, date of birth April 5, 1954?"

"Yes."

"In that case, you were here in August of 1991."

"I did see a dermatologist once, come to think of it. Was that you?"

It's always nice to know you've made a strong impression. Of course, forgetfulness works both ways:

"Nice to meet you, Ms. Jones."

"I saw you last month, Doctor."

Ouch. This usually happens when my staff checks in an old patient as a new one. Sometimes they haven't been able to find the patient's name in the computer (misspellings, data loss, a 20-year absence, whatever). In other cases, the patient has come in with a child or other relative but never registered under his or her own name. I have a pretty good memory, but without a chart, I'm mostly lost.

Unrecognized patients often make allowances. "You have so many patients, Doctor, you can't possibly remember them all." True enough.

I do try, though. People are often flattered when recognized, offended when they're not. (That's why politicians make such a point of remembering everyone.) Knowing who people are is a good start, but recollecting personal details is even better. I often note such details in the chart, whether they're germane to skin complaints or not. The patient may have started a new job, graduated college, bought a condo, planned a honeymoon in Uzbekistan.

When notes jog my memory about such things, I deftly slip in a personal reference while writing a prescription. "The doxycycline is refillable three times, Ned. By the way, how was the bridal suite at the Samarkand Motel 6?"

If the patient exclaims, "You have a good memory! How did you remember that?" I usually confess that I'd written it down. That doesn't seem to offend anybody; instead, they're somewhat pleased to have a stranger show some interest in their nonmedical lives. I do it to make people comfortable and to get to know them a bit, because many of them come back at odd intervals over the course of many years.

I have another reason, too—a dark secret now revealed here for the first time: I occasionally find patients' stories even more riveting than the diagnostic and therapeutic challenges posed by their rashes and skin growths. There, I said it.

Outside the office, I'm even more lost when greeted by patients who know me. By now, I've been around long enough that it's hard to go to the grocery or the gym or to just walk down the street without running into someone who stares, grins, and says, "Dr. Rockoff—is that you?"

I usually admit that it is and smile brightly in apparent recognition, keeping a keen eye out for an escape route before further conversation can unmask my ignorance of who the dickens they are. ("You know me! The one with the rash!") My father, well known in our hometown, was often hailed by strangers. He always smiled heartily and waved back. "Who was that?" I'd ask. "I have no idea," he'd say. "But they seem to know me, so I wave."

Of course, it's hard to recognize people out of context. I think my patients should have an easier time remembering me than I do them; after all, there are so many of them and just one of me. For the most part that's true, but some folks are just better at remembering than others are.

"Nice to meet you, Mr. Steele."

"I met you already."

"Well, actually, the one time you were here before, you saw my associate Henrietta."

"You know, you're right—it was a lady!"

Glad we straightened that out.

Good morning, Mr. Nesia. I see you haven't been here in 15 years."

"I was never here before."

"Forgive me—aren't you Alford M. Nesia, address 36 Endive Gardens Avenue, Boxboro, date of birth April 5, 1954?"

"Yes."

"In that case, you were here in August of 1991."

"I did see a dermatologist once, come to think of it. Was that you?"

It's always nice to know you've made a strong impression. Of course, forgetfulness works both ways:

"Nice to meet you, Ms. Jones."

"I saw you last month, Doctor."

Ouch. This usually happens when my staff checks in an old patient as a new one. Sometimes they haven't been able to find the patient's name in the computer (misspellings, data loss, a 20-year absence, whatever). In other cases, the patient has come in with a child or other relative but never registered under his or her own name. I have a pretty good memory, but without a chart, I'm mostly lost.

Unrecognized patients often make allowances. "You have so many patients, Doctor, you can't possibly remember them all." True enough.

I do try, though. People are often flattered when recognized, offended when they're not. (That's why politicians make such a point of remembering everyone.) Knowing who people are is a good start, but recollecting personal details is even better. I often note such details in the chart, whether they're germane to skin complaints or not. The patient may have started a new job, graduated college, bought a condo, planned a honeymoon in Uzbekistan.

When notes jog my memory about such things, I deftly slip in a personal reference while writing a prescription. "The doxycycline is refillable three times, Ned. By the way, how was the bridal suite at the Samarkand Motel 6?"

If the patient exclaims, "You have a good memory! How did you remember that?" I usually confess that I'd written it down. That doesn't seem to offend anybody; instead, they're somewhat pleased to have a stranger show some interest in their nonmedical lives. I do it to make people comfortable and to get to know them a bit, because many of them come back at odd intervals over the course of many years.

I have another reason, too—a dark secret now revealed here for the first time: I occasionally find patients' stories even more riveting than the diagnostic and therapeutic challenges posed by their rashes and skin growths. There, I said it.

Outside the office, I'm even more lost when greeted by patients who know me. By now, I've been around long enough that it's hard to go to the grocery or the gym or to just walk down the street without running into someone who stares, grins, and says, "Dr. Rockoff—is that you?"

I usually admit that it is and smile brightly in apparent recognition, keeping a keen eye out for an escape route before further conversation can unmask my ignorance of who the dickens they are. ("You know me! The one with the rash!") My father, well known in our hometown, was often hailed by strangers. He always smiled heartily and waved back. "Who was that?" I'd ask. "I have no idea," he'd say. "But they seem to know me, so I wave."

Of course, it's hard to recognize people out of context. I think my patients should have an easier time remembering me than I do them; after all, there are so many of them and just one of me. For the most part that's true, but some folks are just better at remembering than others are.

"Nice to meet you, Mr. Steele."

"I met you already."

"Well, actually, the one time you were here before, you saw my associate Henrietta."

"You know, you're right—it was a lady!"

Glad we straightened that out.

• Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
• At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."

What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.

She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.

Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.

The decision that people make about What Belongs applies to acquired lesions as well.

Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?

Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.

Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?

No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."

The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:

• General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
• System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
• Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."

Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.

In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.

They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.

This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.

The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.

• Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
• At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."

What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.

She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.

Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.

The decision that people make about What Belongs applies to acquired lesions as well.

Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?

Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.

Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?

No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."

The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:

• General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
• System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
• Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."

Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.

In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.

They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.

This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.

The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.

• Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
• At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."

What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.

She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.

Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.

The decision that people make about What Belongs applies to acquired lesions as well.

Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?

Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.

Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?

No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."

The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:

• General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
• System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
• Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."

Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.

In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.

They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.

This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.

The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.

My first exposure to clinical dermatology consisted of a month of Friday morning skin clinics during my second year of pediatric residency. Then, as now, skin disease was judged too unimportant to be taught to medical students.

Three volunteer dermatologists slumming from Manhattan supervised—two men and a woman. Their stylish dress clashed with the dingy decor of a Bronx city hospital OPD. Between patients, they spoke of cars.

My first patient sat on a gurney at the back of an alcove separated from the corridor by a curtain. Because I had no idea what she had, my presentation must have been brief. The three dermatologists followed me back in and took a casual look. Turning to leave, one of the men said, "Pityriasis rubra pilaris." The others nodded, exiting the alcove.

I was astonished. How could they just look at something and know what it was? Much later, I learned their twin secrets:

▸ Knowing from experience.

▸ Making up what you don't know.

What prompted this small reminiscence was a recent essay in the New England Journal of Medicine, "The Demise of the Physical Exam" (2006;354:548–51). In the essay, Dr. Sandeep Jauhar recounts a medical school incident in which he missed an aortic dissection by failing to note that the patient's blood pressure was higher on one side than the other. The way he remembers physical diagnosis instruction sounded familiar: "The preceptor was an intense but likable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. … Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it."

Dr. Jauhar notes several reasons for this dismissal, including lack of time to do a proper physical and the noisy distractions of a hospital milieu. The most important reason, however, is the fact that diagnostic tests just do a better job at making diagnoses. This is true even in comparing chest x-rays with auscultation, and new diagnostic technology of mind-bending sophistication only makes the disparity more glaring. Compared with an MRI, a physical exam seems like something from grandma's attic.

One field of medicine remains, however, where physical examination is alive and well: ours. Most dermatologists with any experience do every day what my long-ago preceptors so amazed me with: walk in, look, diagnose. We don't do a lot of tests. We don't have a lot of tests to do.

Last week, I recorded patients' diagnoses and lab tests on a random day. Of 46 patients, 23 had rashes (acne, psoriasis, and so forth); 5 had bacterial or fungal skin infections; 5 had warts; 11 had lesions of some sort; and 2 had cosmetic-related questions.

The lab test tally for that day was one bacterial skin culture, one fungus culture, one KOH prep, blood tests for a patient taking isotretinoin, and three biopsies.

This seems typical of one of our days. Most of the time, we glance and know at once what we're dealing with. (Managing it is another story.)

For every lesion we biopsy, people show us 20 we diagnose by inspection (visual or dermoscopic). Rashes are mostly clear cut. When they aren't, we biopsy. (And how often does the biopsy of a rash give us a decisive answer?) For many infections, cultures are confirmatory, if not redundant. Drug rashes? Viral exanthems? Clinical diagnoses.

Medical students find all this as weird as I did when first exposed to it. They're so used to watching people order tests—to diagnose, placate senior staff, or ward off phantom attorneys—that their clinical skills atrophy before they develop; they lose it even before they use it. When I ask my students what their impression is of a rash, their eyes widen in a silent plea: You mean I should know just by looking?

Well, yes. As is true of any skill, you can develop it, with instruction and practice.

Without a dermatology elective in school, many physicians carry this primal fear of skin disease indefinitely. "Skin makes me nervous," they tell patients. "See the dermatologist." They think our skills are a little occult.

We dermatologists shouldn't take too much credit for our archaic clinical virtuosity, such as it is. To a large extent, we don't rely on tests because we don't have tests to rely on. If we had more crutches, we would lean on them as much as anyone else does. Our patients would insist.

Meantime, however, we practice in a manner that is alarmingly similar to the way our remote clinical ancestors did.

We walk in, look, and know from experience what's going on. And what we don't know, we make up, assigning a provisional label in the hope that time will clarify things and bail us out—which it often does.

For our small corner of the medical universe, therefore, reports of the demise of the physical exam have been greatly exaggerated.

My first exposure to clinical dermatology consisted of a month of Friday morning skin clinics during my second year of pediatric residency. Then, as now, skin disease was judged too unimportant to be taught to medical students.

Three volunteer dermatologists slumming from Manhattan supervised—two men and a woman. Their stylish dress clashed with the dingy decor of a Bronx city hospital OPD. Between patients, they spoke of cars.

My first patient sat on a gurney at the back of an alcove separated from the corridor by a curtain. Because I had no idea what she had, my presentation must have been brief. The three dermatologists followed me back in and took a casual look. Turning to leave, one of the men said, "Pityriasis rubra pilaris." The others nodded, exiting the alcove.

I was astonished. How could they just look at something and know what it was? Much later, I learned their twin secrets:

▸ Knowing from experience.

▸ Making up what you don't know.

What prompted this small reminiscence was a recent essay in the New England Journal of Medicine, "The Demise of the Physical Exam" (2006;354:548–51). In the essay, Dr. Sandeep Jauhar recounts a medical school incident in which he missed an aortic dissection by failing to note that the patient's blood pressure was higher on one side than the other. The way he remembers physical diagnosis instruction sounded familiar: "The preceptor was an intense but likable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. … Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it."

Dr. Jauhar notes several reasons for this dismissal, including lack of time to do a proper physical and the noisy distractions of a hospital milieu. The most important reason, however, is the fact that diagnostic tests just do a better job at making diagnoses. This is true even in comparing chest x-rays with auscultation, and new diagnostic technology of mind-bending sophistication only makes the disparity more glaring. Compared with an MRI, a physical exam seems like something from grandma's attic.

One field of medicine remains, however, where physical examination is alive and well: ours. Most dermatologists with any experience do every day what my long-ago preceptors so amazed me with: walk in, look, diagnose. We don't do a lot of tests. We don't have a lot of tests to do.

Last week, I recorded patients' diagnoses and lab tests on a random day. Of 46 patients, 23 had rashes (acne, psoriasis, and so forth); 5 had bacterial or fungal skin infections; 5 had warts; 11 had lesions of some sort; and 2 had cosmetic-related questions.

The lab test tally for that day was one bacterial skin culture, one fungus culture, one KOH prep, blood tests for a patient taking isotretinoin, and three biopsies.

This seems typical of one of our days. Most of the time, we glance and know at once what we're dealing with. (Managing it is another story.)

For every lesion we biopsy, people show us 20 we diagnose by inspection (visual or dermoscopic). Rashes are mostly clear cut. When they aren't, we biopsy. (And how often does the biopsy of a rash give us a decisive answer?) For many infections, cultures are confirmatory, if not redundant. Drug rashes? Viral exanthems? Clinical diagnoses.

Medical students find all this as weird as I did when first exposed to it. They're so used to watching people order tests—to diagnose, placate senior staff, or ward off phantom attorneys—that their clinical skills atrophy before they develop; they lose it even before they use it. When I ask my students what their impression is of a rash, their eyes widen in a silent plea: You mean I should know just by looking?

Well, yes. As is true of any skill, you can develop it, with instruction and practice.

Without a dermatology elective in school, many physicians carry this primal fear of skin disease indefinitely. "Skin makes me nervous," they tell patients. "See the dermatologist." They think our skills are a little occult.

We dermatologists shouldn't take too much credit for our archaic clinical virtuosity, such as it is. To a large extent, we don't rely on tests because we don't have tests to rely on. If we had more crutches, we would lean on them as much as anyone else does. Our patients would insist.

Meantime, however, we practice in a manner that is alarmingly similar to the way our remote clinical ancestors did.

We walk in, look, and know from experience what's going on. And what we don't know, we make up, assigning a provisional label in the hope that time will clarify things and bail us out—which it often does.

For our small corner of the medical universe, therefore, reports of the demise of the physical exam have been greatly exaggerated.

My first exposure to clinical dermatology consisted of a month of Friday morning skin clinics during my second year of pediatric residency. Then, as now, skin disease was judged too unimportant to be taught to medical students.

Three volunteer dermatologists slumming from Manhattan supervised—two men and a woman. Their stylish dress clashed with the dingy decor of a Bronx city hospital OPD. Between patients, they spoke of cars.

My first patient sat on a gurney at the back of an alcove separated from the corridor by a curtain. Because I had no idea what she had, my presentation must have been brief. The three dermatologists followed me back in and took a casual look. Turning to leave, one of the men said, "Pityriasis rubra pilaris." The others nodded, exiting the alcove.

I was astonished. How could they just look at something and know what it was? Much later, I learned their twin secrets:

▸ Knowing from experience.

▸ Making up what you don't know.

What prompted this small reminiscence was a recent essay in the New England Journal of Medicine, "The Demise of the Physical Exam" (2006;354:548–51). In the essay, Dr. Sandeep Jauhar recounts a medical school incident in which he missed an aortic dissection by failing to note that the patient's blood pressure was higher on one side than the other. The way he remembers physical diagnosis instruction sounded familiar: "The preceptor was an intense but likable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. … Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it."

Dr. Jauhar notes several reasons for this dismissal, including lack of time to do a proper physical and the noisy distractions of a hospital milieu. The most important reason, however, is the fact that diagnostic tests just do a better job at making diagnoses. This is true even in comparing chest x-rays with auscultation, and new diagnostic technology of mind-bending sophistication only makes the disparity more glaring. Compared with an MRI, a physical exam seems like something from grandma's attic.

One field of medicine remains, however, where physical examination is alive and well: ours. Most dermatologists with any experience do every day what my long-ago preceptors so amazed me with: walk in, look, diagnose. We don't do a lot of tests. We don't have a lot of tests to do.

Last week, I recorded patients' diagnoses and lab tests on a random day. Of 46 patients, 23 had rashes (acne, psoriasis, and so forth); 5 had bacterial or fungal skin infections; 5 had warts; 11 had lesions of some sort; and 2 had cosmetic-related questions.

The lab test tally for that day was one bacterial skin culture, one fungus culture, one KOH prep, blood tests for a patient taking isotretinoin, and three biopsies.

This seems typical of one of our days. Most of the time, we glance and know at once what we're dealing with. (Managing it is another story.)

For every lesion we biopsy, people show us 20 we diagnose by inspection (visual or dermoscopic). Rashes are mostly clear cut. When they aren't, we biopsy. (And how often does the biopsy of a rash give us a decisive answer?) For many infections, cultures are confirmatory, if not redundant. Drug rashes? Viral exanthems? Clinical diagnoses.

Medical students find all this as weird as I did when first exposed to it. They're so used to watching people order tests—to diagnose, placate senior staff, or ward off phantom attorneys—that their clinical skills atrophy before they develop; they lose it even before they use it. When I ask my students what their impression is of a rash, their eyes widen in a silent plea: You mean I should know just by looking?

Well, yes. As is true of any skill, you can develop it, with instruction and practice.

Without a dermatology elective in school, many physicians carry this primal fear of skin disease indefinitely. "Skin makes me nervous," they tell patients. "See the dermatologist." They think our skills are a little occult.

We dermatologists shouldn't take too much credit for our archaic clinical virtuosity, such as it is. To a large extent, we don't rely on tests because we don't have tests to rely on. If we had more crutches, we would lean on them as much as anyone else does. Our patients would insist.

Meantime, however, we practice in a manner that is alarmingly similar to the way our remote clinical ancestors did.

We walk in, look, and know from experience what's going on. And what we don't know, we make up, assigning a provisional label in the hope that time will clarify things and bail us out—which it often does.

For our small corner of the medical universe, therefore, reports of the demise of the physical exam have been greatly exaggerated.

My pager went off Saturday night. Susan was in a panic. "I couldn't log onto the iPledge Web site!" she cried. "I called their number and waited 40 minutes, and they told me you hadn't confirmed contraceptive counseling. If I don't get the medicine Monday, I'll be locked out for a month!"

I know an emergency when I hear one. Susan had already taken isotretinoin for a month, so a 30-day holiday would not do. Springing into action, I logged onto the iPledge Web site, located Susan, and pressed the "Confirm Patient Counseling" tab to verify that I'd told her not to get pregnant. I did that at her visit Thursday, noting that the pregnancy test from Tuesday was negative. No dice. The error message read, "Not enough time has elapsed."

Not enough time? Not enough time for what?

I called the 866 number and had to wait just a few moments, listening to the grating background music, before a human being picked up. I gave her my DEA number.

"I need your date of personal significance," she said.

Other Web sites use secondary passwords you can actually recall, like your mother's maiden name. "I don't know my date of personal significance," I said.

"Would you like to guess?" she said. I guessed my birthday. Wrong.

"We can't speak to providers who don't know their date of personal significance," she said, "unless they answer the phone in their office. Are you in your office?"

"It's 10 o'clock Saturday night," I said. "I'm home."

"Then I can't help you," she said.

"For heaven's sake," I said, "if you call my office, the automated attendant will identify my name. …" Just then I found the memo in my Palm. Of course that was the significant date I'd picked: 9/11/01. Catastrophe.

Now she could help me. Only she couldn't. I stated my problem. "This patient had express registration," she said. "There's no waiting period. It must be a system problem. I'll transfer you to technical support."

Now I had my chance to spend 40 minutes listening every 60 seconds to, "Your call is important to us. Someone will be with you shortly." Eventually someone was.

"May I help you?"

I certainly hoped so.

"I'm exhausted," she said. "I've been working 12 hours, 7 days in a row. And it's busy!"

I commiserated and restated my problem. She put me on hold, then returned. "This patient had express registration," she said. "There's no waiting period. This shouldn't happen."

I agreed.

"'Not enough time has elapsed,'" she read. "What does that mean? It makes no sense!"

"Good point," I concurred.

She tried entering different dates. "Aha!" she said. "I got it to work!"

"What did you do?"

"The contraceptive counseling has to be before the pregnancy test," she said, "Otherwise the system won't take it."

"Does that mean that if my patient takes a pregnancy test Monday and I see her on Wednesday and counsel her then, the counseling doesn't count?" I asked.

"That's a medical question," she said. "I'm not authorized to answer medical questions about the actual program. I'm technical. I just know how to make the Web site work."

"Is the patient all set?" I asked.

"All set!" she said. I told her to go home and get some rest.

I hung up, pleased with another useful job under my belt.

I celebrated too soon, though. As we all know by now, iPledge drollery has degenerated to disaster. Getting Susan her medicine took 3 more days of calls and listening to, "We are experiencing a high call volume. Peak times are 9:00 a.m. until noon. Please call back another time." This message played from 9:00 a.m. to midnight, followed by disconnection. Click. You're dead.

Things will no doubt get better in time. They may expand the number of operators from four to six. Someone familiar with English will change all the "who's" on the Web site to "whose." And maybe they'll figure out a way not to require monthly counseling for males. ("Don't give your pills to pregnant women!" "Take prenatal vitamins!")

They may even improve the music. When you're on hold, that music you are hearing oompahing and sawing away in the background is Mozart's "A Musical Joke."

Please tell me, what warped bureaucrat would choose, from the whole universe of musical possibilities, Mozart's purposely annoying send-up of incompetent composers and instrumentalists?

At least we know whom the joke's on, don't we? Our patients and us.

My pager went off Saturday night. Susan was in a panic. "I couldn't log onto the iPledge Web site!" she cried. "I called their number and waited 40 minutes, and they told me you hadn't confirmed contraceptive counseling. If I don't get the medicine Monday, I'll be locked out for a month!"

I know an emergency when I hear one. Susan had already taken isotretinoin for a month, so a 30-day holiday would not do. Springing into action, I logged onto the iPledge Web site, located Susan, and pressed the "Confirm Patient Counseling" tab to verify that I'd told her not to get pregnant. I did that at her visit Thursday, noting that the pregnancy test from Tuesday was negative. No dice. The error message read, "Not enough time has elapsed."

Not enough time? Not enough time for what?

I called the 866 number and had to wait just a few moments, listening to the grating background music, before a human being picked up. I gave her my DEA number.

"I need your date of personal significance," she said.

Other Web sites use secondary passwords you can actually recall, like your mother's maiden name. "I don't know my date of personal significance," I said.

"Would you like to guess?" she said. I guessed my birthday. Wrong.

"We can't speak to providers who don't know their date of personal significance," she said, "unless they answer the phone in their office. Are you in your office?"

"It's 10 o'clock Saturday night," I said. "I'm home."

"Then I can't help you," she said.

"For heaven's sake," I said, "if you call my office, the automated attendant will identify my name. …" Just then I found the memo in my Palm. Of course that was the significant date I'd picked: 9/11/01. Catastrophe.

Now she could help me. Only she couldn't. I stated my problem. "This patient had express registration," she said. "There's no waiting period. It must be a system problem. I'll transfer you to technical support."

Now I had my chance to spend 40 minutes listening every 60 seconds to, "Your call is important to us. Someone will be with you shortly." Eventually someone was.

"May I help you?"

I certainly hoped so.

"I'm exhausted," she said. "I've been working 12 hours, 7 days in a row. And it's busy!"

I commiserated and restated my problem. She put me on hold, then returned. "This patient had express registration," she said. "There's no waiting period. This shouldn't happen."

I agreed.

"'Not enough time has elapsed,'" she read. "What does that mean? It makes no sense!"

"Good point," I concurred.

She tried entering different dates. "Aha!" she said. "I got it to work!"

"What did you do?"

"The contraceptive counseling has to be before the pregnancy test," she said, "Otherwise the system won't take it."

"Does that mean that if my patient takes a pregnancy test Monday and I see her on Wednesday and counsel her then, the counseling doesn't count?" I asked.

"That's a medical question," she said. "I'm not authorized to answer medical questions about the actual program. I'm technical. I just know how to make the Web site work."

"Is the patient all set?" I asked.

"All set!" she said. I told her to go home and get some rest.

I hung up, pleased with another useful job under my belt.

I celebrated too soon, though. As we all know by now, iPledge drollery has degenerated to disaster. Getting Susan her medicine took 3 more days of calls and listening to, "We are experiencing a high call volume. Peak times are 9:00 a.m. until noon. Please call back another time." This message played from 9:00 a.m. to midnight, followed by disconnection. Click. You're dead.

Things will no doubt get better in time. They may expand the number of operators from four to six. Someone familiar with English will change all the "who's" on the Web site to "whose." And maybe they'll figure out a way not to require monthly counseling for males. ("Don't give your pills to pregnant women!" "Take prenatal vitamins!")

They may even improve the music. When you're on hold, that music you are hearing oompahing and sawing away in the background is Mozart's "A Musical Joke."

Please tell me, what warped bureaucrat would choose, from the whole universe of musical possibilities, Mozart's purposely annoying send-up of incompetent composers and instrumentalists?

At least we know whom the joke's on, don't we? Our patients and us.

My pager went off Saturday night. Susan was in a panic. "I couldn't log onto the iPledge Web site!" she cried. "I called their number and waited 40 minutes, and they told me you hadn't confirmed contraceptive counseling. If I don't get the medicine Monday, I'll be locked out for a month!"

I know an emergency when I hear one. Susan had already taken isotretinoin for a month, so a 30-day holiday would not do. Springing into action, I logged onto the iPledge Web site, located Susan, and pressed the "Confirm Patient Counseling" tab to verify that I'd told her not to get pregnant. I did that at her visit Thursday, noting that the pregnancy test from Tuesday was negative. No dice. The error message read, "Not enough time has elapsed."

Not enough time? Not enough time for what?

I called the 866 number and had to wait just a few moments, listening to the grating background music, before a human being picked up. I gave her my DEA number.

"I need your date of personal significance," she said.

Other Web sites use secondary passwords you can actually recall, like your mother's maiden name. "I don't know my date of personal significance," I said.

"Would you like to guess?" she said. I guessed my birthday. Wrong.

"We can't speak to providers who don't know their date of personal significance," she said, "unless they answer the phone in their office. Are you in your office?"

"It's 10 o'clock Saturday night," I said. "I'm home."

"Then I can't help you," she said.

"For heaven's sake," I said, "if you call my office, the automated attendant will identify my name. …" Just then I found the memo in my Palm. Of course that was the significant date I'd picked: 9/11/01. Catastrophe.

Now she could help me. Only she couldn't. I stated my problem. "This patient had express registration," she said. "There's no waiting period. It must be a system problem. I'll transfer you to technical support."

Now I had my chance to spend 40 minutes listening every 60 seconds to, "Your call is important to us. Someone will be with you shortly." Eventually someone was.

"May I help you?"

I certainly hoped so.

"I'm exhausted," she said. "I've been working 12 hours, 7 days in a row. And it's busy!"

I commiserated and restated my problem. She put me on hold, then returned. "This patient had express registration," she said. "There's no waiting period. This shouldn't happen."

I agreed.

"'Not enough time has elapsed,'" she read. "What does that mean? It makes no sense!"

"Good point," I concurred.

She tried entering different dates. "Aha!" she said. "I got it to work!"

"What did you do?"

"The contraceptive counseling has to be before the pregnancy test," she said, "Otherwise the system won't take it."

"Does that mean that if my patient takes a pregnancy test Monday and I see her on Wednesday and counsel her then, the counseling doesn't count?" I asked.

"That's a medical question," she said. "I'm not authorized to answer medical questions about the actual program. I'm technical. I just know how to make the Web site work."

"Is the patient all set?" I asked.

"All set!" she said. I told her to go home and get some rest.

I hung up, pleased with another useful job under my belt.

I celebrated too soon, though. As we all know by now, iPledge drollery has degenerated to disaster. Getting Susan her medicine took 3 more days of calls and listening to, "We are experiencing a high call volume. Peak times are 9:00 a.m. until noon. Please call back another time." This message played from 9:00 a.m. to midnight, followed by disconnection. Click. You're dead.

Things will no doubt get better in time. They may expand the number of operators from four to six. Someone familiar with English will change all the "who's" on the Web site to "whose." And maybe they'll figure out a way not to require monthly counseling for males. ("Don't give your pills to pregnant women!" "Take prenatal vitamins!")

They may even improve the music. When you're on hold, that music you are hearing oompahing and sawing away in the background is Mozart's "A Musical Joke."

Please tell me, what warped bureaucrat would choose, from the whole universe of musical possibilities, Mozart's purposely annoying send-up of incompetent composers and instrumentalists?

At least we know whom the joke's on, don't we? Our patients and us.