Alan Rockoff

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.

One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.

Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.

But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.

Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.

Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.

My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.

"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"

I was supposed to answer yes, that was bad.

Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.

Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.

QED: scabies.

And if it isn't, hey, what's the worst that could happen?

Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.

The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."

All agree that close physical contact is the most likely source of scabies transmission.

I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.

The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.

It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.

Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.

Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.

One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.

Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.

But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.

Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.

Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.

My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.

"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"

I was supposed to answer yes, that was bad.

Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.

Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.

QED: scabies.

And if it isn't, hey, what's the worst that could happen?

Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.

The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."

All agree that close physical contact is the most likely source of scabies transmission.

I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.

The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.

It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.

Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.

Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.

One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.

Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.

But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.

Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.

Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.

My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.

"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"

I was supposed to answer yes, that was bad.

Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.

Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.

QED: scabies.

And if it isn't, hey, what's the worst that could happen?

Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.

The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."

All agree that close physical contact is the most likely source of scabies transmission.

I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.

The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.

It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.

Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

Good morning, Doctor. I went to another dermatology office, but I'm not going back there. Too risky."

"Too risky?"

"They had a staff infection."

"Let's review your history. Do you have any medical issues?"

"Just my prostrate."

"Any skin problems?"

"My mother says when I was an infant I had ectopic dermatitis."

"And after that?"

"As a teenager my face was clear, but I did have bacne."

"Go on."

"In college I got an irritation in my groinal area."

"A fungus?"

"No, but I did have a fungus on my toenails. The test showed a hermaphrodite infection."

"What about the groin rash?"

"I have it on my scalp and elbows too. The doctor said it was seriosis."

"Did he treat you with anything?"

"I got two creams for the elbows, ones that come from farms in warm climates."

"Farms in warm climates?"

"Cultivate and Tropicort."

"Does this rash come on your face?"

"No, but I do have rosetta there."

"Have you had any growths removed?"

"The kind that run in families. Most of my relatives get bumbs."

"Bumbs?"

"Yes, you know. Like skin ticks. The doctor didn't take them off. He had his PI do it."

"Any skin cancers?"

"I did have two plastic nevi removed. And there was a squamish cell on my arm. It just propped up."

"Did the doctor burn it off?"

"No, I was afraid of scarring so he sent me to a surgeon for an exorcision."

"Any other skin problems?"

"I'm a little embarrassed about this. I was once incarcerated, and I got penal warts."

"Were you treated for them while you were in jail?"

"Yes. It was minimum security."

"What else?"

"Gentile herpes."

"Here's a prescription for an antibiotic for your face. What are you looking at?"

"I can't read it. P O … what does POBID mean?"

"Twice a day by mouth. But you don't have to read it. The pharmacist reads it."

"You mean I get this in a pharmacy?"

"Yes."

"Any pharmacy?"

"Yes."

"Can I take it to Drugtown?"

"Any pharmacy."

"How about PHarmaRiot?"

"Yes, there too. What cream did you use for the groin?"

"I knew you'd ask me that, so I wrote it down. Here it is … Fougera!"

"That's the manufacturer."

"It was white. It came in a tube."

"And?"

"It had a yellow stripe. There was a 5 in it. Why am I thinking of Lucy's husband?"

"Desonide?"

"That's it! Say, can't these steroid creams thin your skin?"

"This one is okay."

"Even for the groinal area?"

"Yes. Here's a prescription. Now what are you looking at?"

"It just says BID, but there isn't any PO."

"The technician at PHarmaRiot will type the instructions in English."

"Weren't you going to give me a prescription for the antibiotic for my face, the one with the PO?"

"I did give it to you. You put it away."

"I can't find it. Could you write another one? And I need a different script for a 3-month mail-away."

"Okay, here."

"You wrote only one refill. The mail-away has to have three refills."

"All right."

"I also need a 3-monther for the groinal cream."

"Three refills?"

"Yes. Doc. I have to go."

"How come?"

"Damned prostrate."

Good morning, Doctor. I went to another dermatology office, but I'm not going back there. Too risky."

"Too risky?"

"They had a staff infection."

"Let's review your history. Do you have any medical issues?"

"Just my prostrate."

"Any skin problems?"

"My mother says when I was an infant I had ectopic dermatitis."

"And after that?"

"As a teenager my face was clear, but I did have bacne."

"Go on."

"In college I got an irritation in my groinal area."

"A fungus?"

"No, but I did have a fungus on my toenails. The test showed a hermaphrodite infection."

"What about the groin rash?"

"I have it on my scalp and elbows too. The doctor said it was seriosis."

"Did he treat you with anything?"

"I got two creams for the elbows, ones that come from farms in warm climates."

"Farms in warm climates?"

"Cultivate and Tropicort."

"Does this rash come on your face?"

"No, but I do have rosetta there."

"Have you had any growths removed?"

"The kind that run in families. Most of my relatives get bumbs."

"Bumbs?"

"Yes, you know. Like skin ticks. The doctor didn't take them off. He had his PI do it."

"Any skin cancers?"

"I did have two plastic nevi removed. And there was a squamish cell on my arm. It just propped up."

"Did the doctor burn it off?"

"No, I was afraid of scarring so he sent me to a surgeon for an exorcision."

"Any other skin problems?"

"I'm a little embarrassed about this. I was once incarcerated, and I got penal warts."

"Were you treated for them while you were in jail?"

"Yes. It was minimum security."

"What else?"

"Gentile herpes."

"Here's a prescription for an antibiotic for your face. What are you looking at?"

"I can't read it. P O … what does POBID mean?"

"Twice a day by mouth. But you don't have to read it. The pharmacist reads it."

"You mean I get this in a pharmacy?"

"Yes."

"Any pharmacy?"

"Yes."

"Can I take it to Drugtown?"

"Any pharmacy."

"How about PHarmaRiot?"

"Yes, there too. What cream did you use for the groin?"

"I knew you'd ask me that, so I wrote it down. Here it is … Fougera!"

"That's the manufacturer."

"It was white. It came in a tube."

"And?"

"It had a yellow stripe. There was a 5 in it. Why am I thinking of Lucy's husband?"

"Desonide?"

"That's it! Say, can't these steroid creams thin your skin?"

"This one is okay."

"Even for the groinal area?"

"Yes. Here's a prescription. Now what are you looking at?"

"It just says BID, but there isn't any PO."

"The technician at PHarmaRiot will type the instructions in English."

"Weren't you going to give me a prescription for the antibiotic for my face, the one with the PO?"

"I did give it to you. You put it away."

"I can't find it. Could you write another one? And I need a different script for a 3-month mail-away."

"Okay, here."

"You wrote only one refill. The mail-away has to have three refills."

"All right."

"I also need a 3-monther for the groinal cream."

"Three refills?"

"Yes. Doc. I have to go."

"How come?"

"Damned prostrate."

Good morning, Doctor. I went to another dermatology office, but I'm not going back there. Too risky."

"Too risky?"

"They had a staff infection."

"Let's review your history. Do you have any medical issues?"

"Just my prostrate."

"Any skin problems?"

"My mother says when I was an infant I had ectopic dermatitis."

"And after that?"

"As a teenager my face was clear, but I did have bacne."

"Go on."

"In college I got an irritation in my groinal area."

"A fungus?"

"No, but I did have a fungus on my toenails. The test showed a hermaphrodite infection."

"What about the groin rash?"

"I have it on my scalp and elbows too. The doctor said it was seriosis."

"Did he treat you with anything?"

"I got two creams for the elbows, ones that come from farms in warm climates."

"Farms in warm climates?"

"Cultivate and Tropicort."

"Does this rash come on your face?"

"No, but I do have rosetta there."

"Have you had any growths removed?"

"The kind that run in families. Most of my relatives get bumbs."

"Bumbs?"

"Yes, you know. Like skin ticks. The doctor didn't take them off. He had his PI do it."

"Any skin cancers?"

"I did have two plastic nevi removed. And there was a squamish cell on my arm. It just propped up."

"Did the doctor burn it off?"

"No, I was afraid of scarring so he sent me to a surgeon for an exorcision."

"Any other skin problems?"

"I'm a little embarrassed about this. I was once incarcerated, and I got penal warts."

"Were you treated for them while you were in jail?"

"Yes. It was minimum security."

"What else?"

"Gentile herpes."

"Here's a prescription for an antibiotic for your face. What are you looking at?"

"I can't read it. P O … what does POBID mean?"

"Twice a day by mouth. But you don't have to read it. The pharmacist reads it."

"You mean I get this in a pharmacy?"

"Yes."

"Any pharmacy?"

"Yes."

"Can I take it to Drugtown?"

"Any pharmacy."

"How about PHarmaRiot?"

"Yes, there too. What cream did you use for the groin?"

"I knew you'd ask me that, so I wrote it down. Here it is … Fougera!"

"That's the manufacturer."

"It was white. It came in a tube."

"And?"

"It had a yellow stripe. There was a 5 in it. Why am I thinking of Lucy's husband?"

"Desonide?"

"That's it! Say, can't these steroid creams thin your skin?"

"This one is okay."

"Even for the groinal area?"

"Yes. Here's a prescription. Now what are you looking at?"

"It just says BID, but there isn't any PO."

"The technician at PHarmaRiot will type the instructions in English."

"Weren't you going to give me a prescription for the antibiotic for my face, the one with the PO?"

"I did give it to you. You put it away."

"I can't find it. Could you write another one? And I need a different script for a 3-month mail-away."

"Okay, here."

"You wrote only one refill. The mail-away has to have three refills."

"All right."

"I also need a 3-monther for the groinal cream."

"Three refills?"

"Yes. Doc. I have to go."

"How come?"

"Damned prostrate."

They removed a mole when I was 17," Claire said, pointing to her knee. The scar had faded to white in the 50 years since.

Claire had come for a body check. Her special concerns were the seborrheic keratoses on her torso. "Do you think," she asked, eyeing them suspiciously, "these spots coming out are from the mole they took off my knee?"

Clinical work involves a bit of ethnography. Understanding other cultures with alien ideas can be hard; it's even harder when the people from the other culture look just like you.

Claire is a retired teacher from a Boston suburb. You would never guess from her dress and demeanor that her concept of the body has little in common with the one they teach in medical school.

The key to understanding Claire lies in the homely word "roots."

Our patients apply it to the common skin growths we treat every day, as in, "Don't these warts have roots, Doctor?"

That sort of question might not matter to us, perhaps, but to some patients it matters a great deal. A 27-year-old woman, a graduate student in physiology of all things, once asked me, "Isn't it true that plantar warts can grow deep, into the bone?"

That it's not true doesn't stop her—and many others—from wondering. Patients distinguish between wart types. ("These warts on my hands look like 'Planter's warts.'") The salient characteristic of Planter's warts is not their plantar location but their presumed roots.

Or consider nevi. It's not uncommon for patients to ask, "Don't these moles have root systems under the skin, like a tree?" One patient used a different analogy. "I understand," he said as he pointed to a dermal nevus on his hip, "that a mole is like an inverted golf tee. Most of it is deep underneath."

It would be a mistake to think that such people are uniquely imaginative or deluded. Their ideas are not universal, but they're out there. What they imply is that the medical conception of the body, assumed to be held by every modern and educated person, in fact lives alongside a very different one, an older concept that supposedly went away but didn't.

To doctors, the body has a skin on the outside; inside are many organs—stomach, liver, coiled intestines, and so forth. To many of our patients, however, the Inside is something dark and undifferentiated. Bad things come out of it that would poison the body if not gotten rid of: urine, feces, sweat, sebum.

Diseases come out of the inside too, as "eruptions" or "breakouts," on the skin. Surface rashes are really "systemic." Before you dismiss these as archaic metaphors, listen as patients call warts on the hands, "a virus in my body."

Patients conceive our innards less like a Frank Netter illustration and more like a gloomy cavern, complete with cobwebs and bats. Below, a boiling lake expels excretions and emits eruptions that waft up and out. Above, ugly branching tendrils criss-cross up to their points of attachment on the roof and walls—these are the "roots" of what is poking out above.

This may sound fanciful, but don't take my word for it. Next time you remove a keratosis, wart, or mole, try telling:

▸ The woman whose irritated SK you're curetting, "These keratoses are just stuck onto the top of the skin. They don't have any roots."

▸ The man whose mole you're shaving, "Moles don't have roots, of course."

▸ The mother of a child with plantar warts, "You might be interested to know that plantar warts are thick, but they're just in the epidermis. They don't have roots."

See how often your statement elicits a look of relief—and revelation. For 50 years, Claire's been waiting for the roots of her mole to pop up somewhere else, so naturally her sprouting keratoses seemed to her to be the Mole's Revenge.

Exploring roots can bring unexpected rewards. Give it a try.

They removed a mole when I was 17," Claire said, pointing to her knee. The scar had faded to white in the 50 years since.

Claire had come for a body check. Her special concerns were the seborrheic keratoses on her torso. "Do you think," she asked, eyeing them suspiciously, "these spots coming out are from the mole they took off my knee?"

Clinical work involves a bit of ethnography. Understanding other cultures with alien ideas can be hard; it's even harder when the people from the other culture look just like you.

Claire is a retired teacher from a Boston suburb. You would never guess from her dress and demeanor that her concept of the body has little in common with the one they teach in medical school.

The key to understanding Claire lies in the homely word "roots."

Our patients apply it to the common skin growths we treat every day, as in, "Don't these warts have roots, Doctor?"

That sort of question might not matter to us, perhaps, but to some patients it matters a great deal. A 27-year-old woman, a graduate student in physiology of all things, once asked me, "Isn't it true that plantar warts can grow deep, into the bone?"

That it's not true doesn't stop her—and many others—from wondering. Patients distinguish between wart types. ("These warts on my hands look like 'Planter's warts.'") The salient characteristic of Planter's warts is not their plantar location but their presumed roots.

Or consider nevi. It's not uncommon for patients to ask, "Don't these moles have root systems under the skin, like a tree?" One patient used a different analogy. "I understand," he said as he pointed to a dermal nevus on his hip, "that a mole is like an inverted golf tee. Most of it is deep underneath."

It would be a mistake to think that such people are uniquely imaginative or deluded. Their ideas are not universal, but they're out there. What they imply is that the medical conception of the body, assumed to be held by every modern and educated person, in fact lives alongside a very different one, an older concept that supposedly went away but didn't.

To doctors, the body has a skin on the outside; inside are many organs—stomach, liver, coiled intestines, and so forth. To many of our patients, however, the Inside is something dark and undifferentiated. Bad things come out of it that would poison the body if not gotten rid of: urine, feces, sweat, sebum.

Diseases come out of the inside too, as "eruptions" or "breakouts," on the skin. Surface rashes are really "systemic." Before you dismiss these as archaic metaphors, listen as patients call warts on the hands, "a virus in my body."

Patients conceive our innards less like a Frank Netter illustration and more like a gloomy cavern, complete with cobwebs and bats. Below, a boiling lake expels excretions and emits eruptions that waft up and out. Above, ugly branching tendrils criss-cross up to their points of attachment on the roof and walls—these are the "roots" of what is poking out above.

This may sound fanciful, but don't take my word for it. Next time you remove a keratosis, wart, or mole, try telling:

▸ The woman whose irritated SK you're curetting, "These keratoses are just stuck onto the top of the skin. They don't have any roots."

▸ The man whose mole you're shaving, "Moles don't have roots, of course."

▸ The mother of a child with plantar warts, "You might be interested to know that plantar warts are thick, but they're just in the epidermis. They don't have roots."

See how often your statement elicits a look of relief—and revelation. For 50 years, Claire's been waiting for the roots of her mole to pop up somewhere else, so naturally her sprouting keratoses seemed to her to be the Mole's Revenge.

Exploring roots can bring unexpected rewards. Give it a try.

They removed a mole when I was 17," Claire said, pointing to her knee. The scar had faded to white in the 50 years since.

Claire had come for a body check. Her special concerns were the seborrheic keratoses on her torso. "Do you think," she asked, eyeing them suspiciously, "these spots coming out are from the mole they took off my knee?"

Clinical work involves a bit of ethnography. Understanding other cultures with alien ideas can be hard; it's even harder when the people from the other culture look just like you.

Claire is a retired teacher from a Boston suburb. You would never guess from her dress and demeanor that her concept of the body has little in common with the one they teach in medical school.

The key to understanding Claire lies in the homely word "roots."

Our patients apply it to the common skin growths we treat every day, as in, "Don't these warts have roots, Doctor?"

That sort of question might not matter to us, perhaps, but to some patients it matters a great deal. A 27-year-old woman, a graduate student in physiology of all things, once asked me, "Isn't it true that plantar warts can grow deep, into the bone?"

That it's not true doesn't stop her—and many others—from wondering. Patients distinguish between wart types. ("These warts on my hands look like 'Planter's warts.'") The salient characteristic of Planter's warts is not their plantar location but their presumed roots.

Or consider nevi. It's not uncommon for patients to ask, "Don't these moles have root systems under the skin, like a tree?" One patient used a different analogy. "I understand," he said as he pointed to a dermal nevus on his hip, "that a mole is like an inverted golf tee. Most of it is deep underneath."

It would be a mistake to think that such people are uniquely imaginative or deluded. Their ideas are not universal, but they're out there. What they imply is that the medical conception of the body, assumed to be held by every modern and educated person, in fact lives alongside a very different one, an older concept that supposedly went away but didn't.

To doctors, the body has a skin on the outside; inside are many organs—stomach, liver, coiled intestines, and so forth. To many of our patients, however, the Inside is something dark and undifferentiated. Bad things come out of it that would poison the body if not gotten rid of: urine, feces, sweat, sebum.

Diseases come out of the inside too, as "eruptions" or "breakouts," on the skin. Surface rashes are really "systemic." Before you dismiss these as archaic metaphors, listen as patients call warts on the hands, "a virus in my body."

Patients conceive our innards less like a Frank Netter illustration and more like a gloomy cavern, complete with cobwebs and bats. Below, a boiling lake expels excretions and emits eruptions that waft up and out. Above, ugly branching tendrils criss-cross up to their points of attachment on the roof and walls—these are the "roots" of what is poking out above.

This may sound fanciful, but don't take my word for it. Next time you remove a keratosis, wart, or mole, try telling:

▸ The woman whose irritated SK you're curetting, "These keratoses are just stuck onto the top of the skin. They don't have any roots."

▸ The man whose mole you're shaving, "Moles don't have roots, of course."

▸ The mother of a child with plantar warts, "You might be interested to know that plantar warts are thick, but they're just in the epidermis. They don't have roots."

See how often your statement elicits a look of relief—and revelation. For 50 years, Claire's been waiting for the roots of her mole to pop up somewhere else, so naturally her sprouting keratoses seemed to her to be the Mole's Revenge.

Exploring roots can bring unexpected rewards. Give it a try.

A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.

Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.

The pathologist called, sounding perplexed. "Was he … around any cacti?"

Drat! I always forget to ask patients whether they've cuddled any cacti.

When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…

Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.

In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.

Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.

Here are a few examples from my own collection:

▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.

Hot-tub folliculitis? No whirlpool baths in the park.

Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?

I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.

▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.

A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.

It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.

Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.

Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.

He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.

▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.

"Have you," I ask, looking mysterious, "had any margaritas lately?"

"Why, yes!" they reply, startled. "In Cancun."

"Where you had your drink in a lounge chair, right?"

They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.

▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.

Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.

Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.

Other vacationers show up with cnidarian tales.

Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.

What counts as exotic depends, of course, on where you live.

Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.

"Do you think we'll get to see poison ivy?" she asked.

I told her we might indeed.

A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.

Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.

The pathologist called, sounding perplexed. "Was he … around any cacti?"

Drat! I always forget to ask patients whether they've cuddled any cacti.

When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…

Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.

In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.

Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.

Here are a few examples from my own collection:

▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.

Hot-tub folliculitis? No whirlpool baths in the park.

Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?

I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.

▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.

A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.

It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.

Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.

Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.

He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.

▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.

"Have you," I ask, looking mysterious, "had any margaritas lately?"

"Why, yes!" they reply, startled. "In Cancun."

"Where you had your drink in a lounge chair, right?"

They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.

▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.

Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.

Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.

Other vacationers show up with cnidarian tales.

Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.

What counts as exotic depends, of course, on where you live.

Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.

"Do you think we'll get to see poison ivy?" she asked.

I told her we might indeed.

A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.

Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.

The pathologist called, sounding perplexed. "Was he … around any cacti?"

Drat! I always forget to ask patients whether they've cuddled any cacti.

When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…

Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.

In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.

Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.

Here are a few examples from my own collection:

▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.

Hot-tub folliculitis? No whirlpool baths in the park.

Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?

I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.

▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.

A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.

It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.

Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.

Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.

He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.

▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.

"Have you," I ask, looking mysterious, "had any margaritas lately?"

"Why, yes!" they reply, startled. "In Cancun."

"Where you had your drink in a lounge chair, right?"

They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.

▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.

Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.

Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.

Other vacationers show up with cnidarian tales.

Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.

What counts as exotic depends, of course, on where you live.

Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.

"Do you think we'll get to see poison ivy?" she asked.

I told her we might indeed.

People like to quote George Santayana, who said that those who forget history are doomed to repeat it. Few realize he was referring to the treatment of cutaneous fungal infections.

OK, he wasn't exactly referring to ringworm, but he could have been.

In complex matters like politics and human relations, history is hard to learn from because no two situations are exactly the same.

Scaly skin rashes, however, are not complicated at all. There are only a few possibilities, the most common of which are fungus and eczema. Two simple tests can distinguish them: a potassium hydroxide (KOH) prep and a culture. Even without testing, simple observation of clinical response should do the trick. A steroid cream makes a fungus worse and eczema better; an antifungal cream makes fungus better and does little or nothing for eczema.

Yet generations of nondermatologists continue to treat inflammatory rashes—nummular eczema, balanitis, submammary intertrigo, and so forth—with antifungal creams. My question is not how they can make that mistake; anyone can make a mistake. My question is why they keep making it. Why do so many experienced clinicians, decade after decade, never seem to get any better at making this straightforward, clear-cut distinction?

A close analysis is needed. The mechanism for perpetuating this simple mistake may shed light on the persistence of errors of greater consequence. I will map the intellectual progress of a doctor I'll call XY, to avoid gender bias. There are four steps:

1. Childhood training. Along with everyone else, XY learns early that skin diseases are connected with dirt. The germs presumed to cause rashes are dirty too, especially fungi. Tell Jane she has eczema and she protests, "But I shower every day!" Joey can't fathom why he breaks out—he washes so often. And of course everybody wears flip-flops in the locker room, since we all know what you catch there.

2. (Non)education. In medical school, XY learns nothing about managing ordinary skin problems. The occasional slide presentation may provide passing mastery of discoid lupus or acanthosis nigricans, conditions of interest to the presenter. XY departs medical school with the same assumptions about the rash-dirt nexus with which he or she entered.

3. Pavlovian reinforcement. When XY encounters skin problems during residency, the rash is always incidental to the patient's true problem: heart disease, cancer, and other illnesses of real importance. If the skin issue is noted at all, senior staff will instruct XY that it is probably fungal and treat accordingly. Should XY have the temerity to suggest otherwise and propose treatment with a topical steroid, faculty will exclaim, "Steroids weaken the immune system—you can't put them on an infection!" XY won't make that mistake again.

4. Indifference. Clinical practice will provide XY with few stimuli to unlearn default fungal assumption. When the disease at hand is actually fungal, antifungal creams make the patients better. More often, such creams are irrelevant except as emollients, but the patients don't call to complain. Perhaps the rash never bothered them that much, or the eczema remitted on its own. XY therefore never discovers the error. More severe rashes may generate a dermatologic consultation. The dermatologist's referral letter is read with little interest, if any. XY expects no collegial pats on the back for getting rashes right, fears no lawsuit or public ridicule at grand rounds for getting them wrong.

The mistake therefore does not correct itself, and life goes on.

Santayana notwithstanding, history lessons are hard to learn. When matters are complex, its lessons may be nuanced and ambiguous. What history teaches may be hard to understand or painful to accept.

Then again we may not learn because of simple indifference; we just aren't motivated to bother. Glory and shame are good motivators. Professional integrity and intellectual curiosity should work too, but the evidence suggests they often don't. XY is not interested in learning the distinction between fungus and eczema, XY's educators are not interested in teaching it, and XY's patients aren't bothered enough by the problem to bring the issue to a head.

We all make mistakes. Scaly skin rashes are just an example of the process by which we can go on making the same ones. It might be useful now and then to stop and investigate how many errors we make every day because we can't be bothered to find out that we made them.

People like to quote George Santayana, who said that those who forget history are doomed to repeat it. Few realize he was referring to the treatment of cutaneous fungal infections.

OK, he wasn't exactly referring to ringworm, but he could have been.

In complex matters like politics and human relations, history is hard to learn from because no two situations are exactly the same.

Scaly skin rashes, however, are not complicated at all. There are only a few possibilities, the most common of which are fungus and eczema. Two simple tests can distinguish them: a potassium hydroxide (KOH) prep and a culture. Even without testing, simple observation of clinical response should do the trick. A steroid cream makes a fungus worse and eczema better; an antifungal cream makes fungus better and does little or nothing for eczema.

Yet generations of nondermatologists continue to treat inflammatory rashes—nummular eczema, balanitis, submammary intertrigo, and so forth—with antifungal creams. My question is not how they can make that mistake; anyone can make a mistake. My question is why they keep making it. Why do so many experienced clinicians, decade after decade, never seem to get any better at making this straightforward, clear-cut distinction?

A close analysis is needed. The mechanism for perpetuating this simple mistake may shed light on the persistence of errors of greater consequence. I will map the intellectual progress of a doctor I'll call XY, to avoid gender bias. There are four steps:

1. Childhood training. Along with everyone else, XY learns early that skin diseases are connected with dirt. The germs presumed to cause rashes are dirty too, especially fungi. Tell Jane she has eczema and she protests, "But I shower every day!" Joey can't fathom why he breaks out—he washes so often. And of course everybody wears flip-flops in the locker room, since we all know what you catch there.

2. (Non)education. In medical school, XY learns nothing about managing ordinary skin problems. The occasional slide presentation may provide passing mastery of discoid lupus or acanthosis nigricans, conditions of interest to the presenter. XY departs medical school with the same assumptions about the rash-dirt nexus with which he or she entered.

3. Pavlovian reinforcement. When XY encounters skin problems during residency, the rash is always incidental to the patient's true problem: heart disease, cancer, and other illnesses of real importance. If the skin issue is noted at all, senior staff will instruct XY that it is probably fungal and treat accordingly. Should XY have the temerity to suggest otherwise and propose treatment with a topical steroid, faculty will exclaim, "Steroids weaken the immune system—you can't put them on an infection!" XY won't make that mistake again.

4. Indifference. Clinical practice will provide XY with few stimuli to unlearn default fungal assumption. When the disease at hand is actually fungal, antifungal creams make the patients better. More often, such creams are irrelevant except as emollients, but the patients don't call to complain. Perhaps the rash never bothered them that much, or the eczema remitted on its own. XY therefore never discovers the error. More severe rashes may generate a dermatologic consultation. The dermatologist's referral letter is read with little interest, if any. XY expects no collegial pats on the back for getting rashes right, fears no lawsuit or public ridicule at grand rounds for getting them wrong.

The mistake therefore does not correct itself, and life goes on.

Santayana notwithstanding, history lessons are hard to learn. When matters are complex, its lessons may be nuanced and ambiguous. What history teaches may be hard to understand or painful to accept.

Then again we may not learn because of simple indifference; we just aren't motivated to bother. Glory and shame are good motivators. Professional integrity and intellectual curiosity should work too, but the evidence suggests they often don't. XY is not interested in learning the distinction between fungus and eczema, XY's educators are not interested in teaching it, and XY's patients aren't bothered enough by the problem to bring the issue to a head.

We all make mistakes. Scaly skin rashes are just an example of the process by which we can go on making the same ones. It might be useful now and then to stop and investigate how many errors we make every day because we can't be bothered to find out that we made them.

People like to quote George Santayana, who said that those who forget history are doomed to repeat it. Few realize he was referring to the treatment of cutaneous fungal infections.

OK, he wasn't exactly referring to ringworm, but he could have been.

In complex matters like politics and human relations, history is hard to learn from because no two situations are exactly the same.

Scaly skin rashes, however, are not complicated at all. There are only a few possibilities, the most common of which are fungus and eczema. Two simple tests can distinguish them: a potassium hydroxide (KOH) prep and a culture. Even without testing, simple observation of clinical response should do the trick. A steroid cream makes a fungus worse and eczema better; an antifungal cream makes fungus better and does little or nothing for eczema.

Yet generations of nondermatologists continue to treat inflammatory rashes—nummular eczema, balanitis, submammary intertrigo, and so forth—with antifungal creams. My question is not how they can make that mistake; anyone can make a mistake. My question is why they keep making it. Why do so many experienced clinicians, decade after decade, never seem to get any better at making this straightforward, clear-cut distinction?

A close analysis is needed. The mechanism for perpetuating this simple mistake may shed light on the persistence of errors of greater consequence. I will map the intellectual progress of a doctor I'll call XY, to avoid gender bias. There are four steps:

1. Childhood training. Along with everyone else, XY learns early that skin diseases are connected with dirt. The germs presumed to cause rashes are dirty too, especially fungi. Tell Jane she has eczema and she protests, "But I shower every day!" Joey can't fathom why he breaks out—he washes so often. And of course everybody wears flip-flops in the locker room, since we all know what you catch there.

2. (Non)education. In medical school, XY learns nothing about managing ordinary skin problems. The occasional slide presentation may provide passing mastery of discoid lupus or acanthosis nigricans, conditions of interest to the presenter. XY departs medical school with the same assumptions about the rash-dirt nexus with which he or she entered.

3. Pavlovian reinforcement. When XY encounters skin problems during residency, the rash is always incidental to the patient's true problem: heart disease, cancer, and other illnesses of real importance. If the skin issue is noted at all, senior staff will instruct XY that it is probably fungal and treat accordingly. Should XY have the temerity to suggest otherwise and propose treatment with a topical steroid, faculty will exclaim, "Steroids weaken the immune system—you can't put them on an infection!" XY won't make that mistake again.

4. Indifference. Clinical practice will provide XY with few stimuli to unlearn default fungal assumption. When the disease at hand is actually fungal, antifungal creams make the patients better. More often, such creams are irrelevant except as emollients, but the patients don't call to complain. Perhaps the rash never bothered them that much, or the eczema remitted on its own. XY therefore never discovers the error. More severe rashes may generate a dermatologic consultation. The dermatologist's referral letter is read with little interest, if any. XY expects no collegial pats on the back for getting rashes right, fears no lawsuit or public ridicule at grand rounds for getting them wrong.

The mistake therefore does not correct itself, and life goes on.

Santayana notwithstanding, history lessons are hard to learn. When matters are complex, its lessons may be nuanced and ambiguous. What history teaches may be hard to understand or painful to accept.

Then again we may not learn because of simple indifference; we just aren't motivated to bother. Glory and shame are good motivators. Professional integrity and intellectual curiosity should work too, but the evidence suggests they often don't. XY is not interested in learning the distinction between fungus and eczema, XY's educators are not interested in teaching it, and XY's patients aren't bothered enough by the problem to bring the issue to a head.

We all make mistakes. Scaly skin rashes are just an example of the process by which we can go on making the same ones. It might be useful now and then to stop and investigate how many errors we make every day because we can't be bothered to find out that we made them.

Dear Children,

You adorable little tykes sure don't hold things back the way we grownups do (sometimes). If you think it, you say it.

That's why I'm so grateful to you for asking your Mom, "What are those ugly brown spots on your hands?" Or telling Dad to stop scratching and making fun of him for being so pale. Or letting Grandma know how much you hate those hanging things on her neck.

Your teacher, Ms. Beecher, has been on medical leave for a month. She sits at her mirror and picks at her acne just thinking about what you'd say if you saw her.

George Washington said that honesty is the best policy. Your honesty really works for me.

Thanks!

Dear Infant,

Besides the producers of Teletubbies, no one gives you the credit you deserve for noticing things.

I appreciate you, though. Like when your Mom comes in to have me remove a mole on her chest because you grab at it while you're nursing. Or when you're a little older and point to some mark and yell, "Boo boo!"

You hate bumps, you little devil, don't you? They violate your cute baby sense of order and regularity. When you grow up, you and your health insurer will have fun arguing the exact meaning of "cosmetic" and listing reasons that make it OK for you to get rid of the bumps you've been pointing and grabbing at forever.

Send me those boo-boos!

Goo.

Dear Manicurist/Pedicurist,

I don't know how to thank you for your ongoing project of calling everything you see a fungus. People think that anyway—it really grosses them out—but hearing your expert opinion clinches things. Plus, when you jab at their cuticles, they worry that you're not just diagnosing disease, but causing it.

Of course, I sometimes have trouble talking them out of demanding fungus pills that won't help, but at least they come to the office.

Remember—every nail discoloration or irregularity is a fungus. But you knew that.

Ciao.

Dear Internet,

Web, you really rock!

It used to be that self-diagnosers had to go to a bookstore or library and lug home heavy symptom books, risking back strain or hernia. Now a few mouse clicks in the comfort of their own den, and there's no disease on Earth they can't learn about, see pictures of, and share neuroses and therapeutic advice with sufferers from.

A spot on the groin? Herpes! Fever and a rash? AIDS! Dry lips? Chapstick addiction! A sore belly? Kala-azar! Without you, patients would never even hear about a 10th of the things they now worry about in encyclopedic detail.

Talking them out of these diagnoses and therapies can be tricky. Yet who can argue with the merits of Jeri-Gel for striae and Sculpt-a-Butt for cellulite, with their unconditional, money-back guarantees? Or with green tea compresses and decoctions for everything from asthma to wrinkles to periodontal disease? Or with a 30-page chat-room string on Grover's disease, touting everything from prednisone to Solaraze?

So whether you're academic and ponderous, lay oriented and flip, or just the cyberequivalent of a nosy neighbor, thanks for your support!

Dear Mammography Technician,

I don't know whether seborrheic keratoses really do cast shadows on mammograms, but your concern over them in the mammography field sure generates a lot of referrals. Women are anxious about their breasts anyway, so telling them, "You'd better get that off!" is a great help.

Thanks.

Dear Camera,

Whoever asked for the power to see ourselves as others see us must have had you in mind. Seeing your mug in a photo, or even worse, on camera, has an effect similar to hearing your voice on a tape recording—an acute wish to hide under a rock. With pictures, however, the discomfort is more specific: "Good grief—how long have I had that thing on my cheek?!"

Thanks for the referrals.

Dear Physician,

I sometimes write you in my capacity of consulting colleague, even though the tenor of your referral is often on the order of, "Madge at the front desk has the names of a coupla skin guys. Whyncha pick one?"

At other times, though, the patient comes not because you sent her, but because you walked into the exam room and exclaimed, "WHAT THE DICKENS IS THAT??!!" I've heard too many such tales to dismiss them as poor reporting.

There seems to be something about skin disease that induces exclamations of visceral alarm that go beyond mere perplexity. Other diseases may be pretty inscrutable, yet I can't imagine a doctor looking at a lab report and crying, "Omigosh—your kidneys are a wreck! Check with Madge—she has a list of nephro guys."

Although it might be more professional if you deleted those expletives, I do appreciate your sending folks over.

Sincere thanks to all of you,

A. Derm, M.D.

Dear Children,

You adorable little tykes sure don't hold things back the way we grownups do (sometimes). If you think it, you say it.

That's why I'm so grateful to you for asking your Mom, "What are those ugly brown spots on your hands?" Or telling Dad to stop scratching and making fun of him for being so pale. Or letting Grandma know how much you hate those hanging things on her neck.

Your teacher, Ms. Beecher, has been on medical leave for a month. She sits at her mirror and picks at her acne just thinking about what you'd say if you saw her.

George Washington said that honesty is the best policy. Your honesty really works for me.

Thanks!

Dear Infant,

Besides the producers of Teletubbies, no one gives you the credit you deserve for noticing things.

I appreciate you, though. Like when your Mom comes in to have me remove a mole on her chest because you grab at it while you're nursing. Or when you're a little older and point to some mark and yell, "Boo boo!"

You hate bumps, you little devil, don't you? They violate your cute baby sense of order and regularity. When you grow up, you and your health insurer will have fun arguing the exact meaning of "cosmetic" and listing reasons that make it OK for you to get rid of the bumps you've been pointing and grabbing at forever.

Send me those boo-boos!

Goo.

Dear Manicurist/Pedicurist,

I don't know how to thank you for your ongoing project of calling everything you see a fungus. People think that anyway—it really grosses them out—but hearing your expert opinion clinches things. Plus, when you jab at their cuticles, they worry that you're not just diagnosing disease, but causing it.

Of course, I sometimes have trouble talking them out of demanding fungus pills that won't help, but at least they come to the office.

Remember—every nail discoloration or irregularity is a fungus. But you knew that.

Ciao.

Dear Internet,

Web, you really rock!

It used to be that self-diagnosers had to go to a bookstore or library and lug home heavy symptom books, risking back strain or hernia. Now a few mouse clicks in the comfort of their own den, and there's no disease on Earth they can't learn about, see pictures of, and share neuroses and therapeutic advice with sufferers from.

A spot on the groin? Herpes! Fever and a rash? AIDS! Dry lips? Chapstick addiction! A sore belly? Kala-azar! Without you, patients would never even hear about a 10th of the things they now worry about in encyclopedic detail.

Talking them out of these diagnoses and therapies can be tricky. Yet who can argue with the merits of Jeri-Gel for striae and Sculpt-a-Butt for cellulite, with their unconditional, money-back guarantees? Or with green tea compresses and decoctions for everything from asthma to wrinkles to periodontal disease? Or with a 30-page chat-room string on Grover's disease, touting everything from prednisone to Solaraze?

So whether you're academic and ponderous, lay oriented and flip, or just the cyberequivalent of a nosy neighbor, thanks for your support!

Dear Mammography Technician,

I don't know whether seborrheic keratoses really do cast shadows on mammograms, but your concern over them in the mammography field sure generates a lot of referrals. Women are anxious about their breasts anyway, so telling them, "You'd better get that off!" is a great help.

Thanks.

Dear Camera,

Whoever asked for the power to see ourselves as others see us must have had you in mind. Seeing your mug in a photo, or even worse, on camera, has an effect similar to hearing your voice on a tape recording—an acute wish to hide under a rock. With pictures, however, the discomfort is more specific: "Good grief—how long have I had that thing on my cheek?!"

Thanks for the referrals.

Dear Physician,

I sometimes write you in my capacity of consulting colleague, even though the tenor of your referral is often on the order of, "Madge at the front desk has the names of a coupla skin guys. Whyncha pick one?"

At other times, though, the patient comes not because you sent her, but because you walked into the exam room and exclaimed, "WHAT THE DICKENS IS THAT??!!" I've heard too many such tales to dismiss them as poor reporting.

There seems to be something about skin disease that induces exclamations of visceral alarm that go beyond mere perplexity. Other diseases may be pretty inscrutable, yet I can't imagine a doctor looking at a lab report and crying, "Omigosh—your kidneys are a wreck! Check with Madge—she has a list of nephro guys."

Although it might be more professional if you deleted those expletives, I do appreciate your sending folks over.

Sincere thanks to all of you,

A. Derm, M.D.

Dear Children,

You adorable little tykes sure don't hold things back the way we grownups do (sometimes). If you think it, you say it.

That's why I'm so grateful to you for asking your Mom, "What are those ugly brown spots on your hands?" Or telling Dad to stop scratching and making fun of him for being so pale. Or letting Grandma know how much you hate those hanging things on her neck.

Your teacher, Ms. Beecher, has been on medical leave for a month. She sits at her mirror and picks at her acne just thinking about what you'd say if you saw her.

George Washington said that honesty is the best policy. Your honesty really works for me.

Thanks!

Dear Infant,

Besides the producers of Teletubbies, no one gives you the credit you deserve for noticing things.

I appreciate you, though. Like when your Mom comes in to have me remove a mole on her chest because you grab at it while you're nursing. Or when you're a little older and point to some mark and yell, "Boo boo!"

You hate bumps, you little devil, don't you? They violate your cute baby sense of order and regularity. When you grow up, you and your health insurer will have fun arguing the exact meaning of "cosmetic" and listing reasons that make it OK for you to get rid of the bumps you've been pointing and grabbing at forever.

Send me those boo-boos!

Goo.

Dear Manicurist/Pedicurist,

I don't know how to thank you for your ongoing project of calling everything you see a fungus. People think that anyway—it really grosses them out—but hearing your expert opinion clinches things. Plus, when you jab at their cuticles, they worry that you're not just diagnosing disease, but causing it.

Of course, I sometimes have trouble talking them out of demanding fungus pills that won't help, but at least they come to the office.

Remember—every nail discoloration or irregularity is a fungus. But you knew that.

Ciao.

Dear Internet,

Web, you really rock!

It used to be that self-diagnosers had to go to a bookstore or library and lug home heavy symptom books, risking back strain or hernia. Now a few mouse clicks in the comfort of their own den, and there's no disease on Earth they can't learn about, see pictures of, and share neuroses and therapeutic advice with sufferers from.

A spot on the groin? Herpes! Fever and a rash? AIDS! Dry lips? Chapstick addiction! A sore belly? Kala-azar! Without you, patients would never even hear about a 10th of the things they now worry about in encyclopedic detail.

Talking them out of these diagnoses and therapies can be tricky. Yet who can argue with the merits of Jeri-Gel for striae and Sculpt-a-Butt for cellulite, with their unconditional, money-back guarantees? Or with green tea compresses and decoctions for everything from asthma to wrinkles to periodontal disease? Or with a 30-page chat-room string on Grover's disease, touting everything from prednisone to Solaraze?

So whether you're academic and ponderous, lay oriented and flip, or just the cyberequivalent of a nosy neighbor, thanks for your support!

Dear Mammography Technician,

I don't know whether seborrheic keratoses really do cast shadows on mammograms, but your concern over them in the mammography field sure generates a lot of referrals. Women are anxious about their breasts anyway, so telling them, "You'd better get that off!" is a great help.

Thanks.

Dear Camera,

Whoever asked for the power to see ourselves as others see us must have had you in mind. Seeing your mug in a photo, or even worse, on camera, has an effect similar to hearing your voice on a tape recording—an acute wish to hide under a rock. With pictures, however, the discomfort is more specific: "Good grief—how long have I had that thing on my cheek?!"

Thanks for the referrals.

Dear Physician,

I sometimes write you in my capacity of consulting colleague, even though the tenor of your referral is often on the order of, "Madge at the front desk has the names of a coupla skin guys. Whyncha pick one?"

At other times, though, the patient comes not because you sent her, but because you walked into the exam room and exclaimed, "WHAT THE DICKENS IS THAT??!!" I've heard too many such tales to dismiss them as poor reporting.

There seems to be something about skin disease that induces exclamations of visceral alarm that go beyond mere perplexity. Other diseases may be pretty inscrutable, yet I can't imagine a doctor looking at a lab report and crying, "Omigosh—your kidneys are a wreck! Check with Madge—she has a list of nephro guys."

Although it might be more professional if you deleted those expletives, I do appreciate your sending folks over.

Sincere thanks to all of you,

A. Derm, M.D.

If you ask patients not just why they came but why they came now, you'll often find that a third party was involved. Whatever is wrong may have been there for some time, raising no concern in the patient's mind until someone else stared at it and warned, "You'd better get that taken care of!"

Now and then this is a colleague. In that case, I can write a letter acknowledging the referral:

Dear Chip,

Thanks so much for referring Mr. Halsey Gribness. I assured him that his red spot is not Lyme disease, adding that whatever bit him had more legs than he does. His honeymoon safari to Ecuador sounds special. Mrs. Gribness is recovering nicely. I simply can't thank you enough for allowing me to participate in the care of this most pleasant gentleman.

Collegially …

Far more often, though, no doctor played any role in encouraging the patient to show up; other, nonmedical sources did the job.

I would love to send notes acknowledging their referrals, too, but most of the time I don't know how to reach them. I will therefore devote my next two columns to thanking these referrers. I assume they subscribe to SKIN & ALLERGY NEWS. If they don't, they should.

Dear Parent/Significant Other:

Helping someone near and dear to overcome inertia takes resolute encouragement; the technical term for this is "nagging." Without your efforts, Ken might never have shown me that mole, and the thing on Jen's nose would have just kept on getting bigger.

Special thanks to the women among you, because you take the responsibility for health matters that your men secretly rely on while pretending to be annoyed.

Telling Stanley, "If you don't have that brown spot looked at, don't come home for Thanksgiving," was a bit strong, but love's got to be tough sometimes.

Keep up that resolute encouragement!

Dear Patient's Coworker:

Now that the water cooler has been replaced by the Intranet and instant messaging, you have so many more opportunities to share diagnostic and therapeutic advice. To tell the truth, I don't think I would discuss with my wife half the things my patients seem to have kicked around with the whole human resources department. You guys really know a lot! You've seen cases just like Bill's, recommended treatments you're sure are bound to work for rashes like Jill's, seen how things ended (usually badly) when growths like Phil's weren't taken care of in time.

Of course you don't even have to actually say anything to generate a visit to my office. Staring at the warts on Syl's hands as she typed at the adjacent keyboard, all the while maintaining a tactful silence, did the trick. So did squirming as Will scratched at the board meeting.

Keep those referrals coming!

Dear Hairdresser:

You guys and gals have a unique perspective—you stand over people and look down at a part of the body that is important but seldom seen. So when you say, "Mabel, you're really thinning out, I can see your scalp!" you get her attention. You pick up cases of psoriasis and alopecia people didn't know they had and spot moles they didn't know were there. You have great moral authority, too. If Hermione is wavering, telling her there is no way you'll take responsibility for putting a chemical color on that until a doctor says it's OK sends her right over to me.

If I had any hair, I would thank you in person.

Dear Magnifying Mirror:

Just when failing close-up vision threatens to make my patients ignore those minor imperfections, you step in to save the day. I looked at myself in one of you recently—scary! My pores looked like the far side of the moon, and the mottling under my eyes reminded me of potato blight. I'd consult myself if I could get a referral.

To be continued …

If you ask patients not just why they came but why they came now, you'll often find that a third party was involved. Whatever is wrong may have been there for some time, raising no concern in the patient's mind until someone else stared at it and warned, "You'd better get that taken care of!"

Now and then this is a colleague. In that case, I can write a letter acknowledging the referral:

Dear Chip,

Thanks so much for referring Mr. Halsey Gribness. I assured him that his red spot is not Lyme disease, adding that whatever bit him had more legs than he does. His honeymoon safari to Ecuador sounds special. Mrs. Gribness is recovering nicely. I simply can't thank you enough for allowing me to participate in the care of this most pleasant gentleman.

Collegially …

Far more often, though, no doctor played any role in encouraging the patient to show up; other, nonmedical sources did the job.

I would love to send notes acknowledging their referrals, too, but most of the time I don't know how to reach them. I will therefore devote my next two columns to thanking these referrers. I assume they subscribe to SKIN & ALLERGY NEWS. If they don't, they should.

Dear Parent/Significant Other:

Helping someone near and dear to overcome inertia takes resolute encouragement; the technical term for this is "nagging." Without your efforts, Ken might never have shown me that mole, and the thing on Jen's nose would have just kept on getting bigger.

Special thanks to the women among you, because you take the responsibility for health matters that your men secretly rely on while pretending to be annoyed.

Telling Stanley, "If you don't have that brown spot looked at, don't come home for Thanksgiving," was a bit strong, but love's got to be tough sometimes.

Keep up that resolute encouragement!

Dear Patient's Coworker:

Now that the water cooler has been replaced by the Intranet and instant messaging, you have so many more opportunities to share diagnostic and therapeutic advice. To tell the truth, I don't think I would discuss with my wife half the things my patients seem to have kicked around with the whole human resources department. You guys really know a lot! You've seen cases just like Bill's, recommended treatments you're sure are bound to work for rashes like Jill's, seen how things ended (usually badly) when growths like Phil's weren't taken care of in time.

Of course you don't even have to actually say anything to generate a visit to my office. Staring at the warts on Syl's hands as she typed at the adjacent keyboard, all the while maintaining a tactful silence, did the trick. So did squirming as Will scratched at the board meeting.

Keep those referrals coming!

Dear Hairdresser:

You guys and gals have a unique perspective—you stand over people and look down at a part of the body that is important but seldom seen. So when you say, "Mabel, you're really thinning out, I can see your scalp!" you get her attention. You pick up cases of psoriasis and alopecia people didn't know they had and spot moles they didn't know were there. You have great moral authority, too. If Hermione is wavering, telling her there is no way you'll take responsibility for putting a chemical color on that until a doctor says it's OK sends her right over to me.

If I had any hair, I would thank you in person.

Dear Magnifying Mirror:

Just when failing close-up vision threatens to make my patients ignore those minor imperfections, you step in to save the day. I looked at myself in one of you recently—scary! My pores looked like the far side of the moon, and the mottling under my eyes reminded me of potato blight. I'd consult myself if I could get a referral.

To be continued …

If you ask patients not just why they came but why they came now, you'll often find that a third party was involved. Whatever is wrong may have been there for some time, raising no concern in the patient's mind until someone else stared at it and warned, "You'd better get that taken care of!"

Now and then this is a colleague. In that case, I can write a letter acknowledging the referral:

Dear Chip,

Thanks so much for referring Mr. Halsey Gribness. I assured him that his red spot is not Lyme disease, adding that whatever bit him had more legs than he does. His honeymoon safari to Ecuador sounds special. Mrs. Gribness is recovering nicely. I simply can't thank you enough for allowing me to participate in the care of this most pleasant gentleman.

Collegially …

Far more often, though, no doctor played any role in encouraging the patient to show up; other, nonmedical sources did the job.

I would love to send notes acknowledging their referrals, too, but most of the time I don't know how to reach them. I will therefore devote my next two columns to thanking these referrers. I assume they subscribe to SKIN & ALLERGY NEWS. If they don't, they should.

Dear Parent/Significant Other:

Helping someone near and dear to overcome inertia takes resolute encouragement; the technical term for this is "nagging." Without your efforts, Ken might never have shown me that mole, and the thing on Jen's nose would have just kept on getting bigger.

Special thanks to the women among you, because you take the responsibility for health matters that your men secretly rely on while pretending to be annoyed.

Telling Stanley, "If you don't have that brown spot looked at, don't come home for Thanksgiving," was a bit strong, but love's got to be tough sometimes.

Keep up that resolute encouragement!

Dear Patient's Coworker:

Now that the water cooler has been replaced by the Intranet and instant messaging, you have so many more opportunities to share diagnostic and therapeutic advice. To tell the truth, I don't think I would discuss with my wife half the things my patients seem to have kicked around with the whole human resources department. You guys really know a lot! You've seen cases just like Bill's, recommended treatments you're sure are bound to work for rashes like Jill's, seen how things ended (usually badly) when growths like Phil's weren't taken care of in time.

Of course you don't even have to actually say anything to generate a visit to my office. Staring at the warts on Syl's hands as she typed at the adjacent keyboard, all the while maintaining a tactful silence, did the trick. So did squirming as Will scratched at the board meeting.

Keep those referrals coming!

Dear Hairdresser:

You guys and gals have a unique perspective—you stand over people and look down at a part of the body that is important but seldom seen. So when you say, "Mabel, you're really thinning out, I can see your scalp!" you get her attention. You pick up cases of psoriasis and alopecia people didn't know they had and spot moles they didn't know were there. You have great moral authority, too. If Hermione is wavering, telling her there is no way you'll take responsibility for putting a chemical color on that until a doctor says it's OK sends her right over to me.

If I had any hair, I would thank you in person.

Dear Magnifying Mirror:

Just when failing close-up vision threatens to make my patients ignore those minor imperfections, you step in to save the day. I looked at myself in one of you recently—scary! My pores looked like the far side of the moon, and the mottling under my eyes reminded me of potato blight. I'd consult myself if I could get a referral.

To be continued …

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?