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As of 2020, Dr. Rockoff began writing the quarterly column "Pruritus Emeritus."
Tyranny by the numbers
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
“How come you retired?” I asked.
A few years my junior, Marty had taught in public school forever. “It was the MCAS,” he said. That’s the Massachusetts Comprehensive Assessment System, a standardized test meant to gauge student performance and teacher competence.
“They demanded that my students test at a fifth-grade level,” Marty said. “But they were all at a second-grade level.
“Plus, I had been teaching for thirty years, and some kid right out of college was telling me how to do my job. So I left.”
Of course, this tale will sound familiar to physicians. Pay for performance. Bean counters calling the shots. Dismissal of clinical experience as useless and self-serving.
A recent book lays it all out: Jerry Z. Muller’s The Tyranny of Metrics. This book is punchy, witty, and succinct – you can read it in a day. A historian of economics and culture, Muller shows the extent of what I had guessed at from chats with people in different fields. In all of these, if you don’t count it, it doesn’t count.
Metrics, it is assumed, are “hard” and “objective.” They must “replace judgment based on experience with standardized measurement.” Their promise is transparency, efficiency, accountability.
Muller began to study this when he became chair of his academic department. He thought his job was to nurture scholars and help students learn, only to find much of his time taken up with feeding often worthless data to remote administrators. He traces the metrical impulse, at root, to lack of trust. It’s not only doctors whom society doesn’t trust, but experts of all kinds.
Principal agents ... “employed in institutions are not to be trusted … their activity must be monitored and measured ... those measures need to be transparent to those without firsthand knowledge of the institutions ... and ... pecuniary rewards and punishments are the best way to motivate ‘agents.’ ”
What this analysis ignores, argues Muller, is that professionals respond not just to “extrinsic motivation[s]” (money) but to intrinsic ones: commitment to profession and clients, doing the right thing, making people happier and better, being recognized and honored by peers, doing interesting and stimulating work. When society denigrates and dismisses those considerations, professionals become demoralized. They leave, or they learn to game the system.
Muller gives many examples. Punish hospitals for readmissions within 30 days of discharge? Fine – readmit patients under “observation status” and call them outpatients. Dock hospitals for deaths within 30 days of leaving? Keep the respirator on for an extra day, and let the patient die on day 31. Risky case? Don’t operate. “Juking the stats” – arresting many small-fry drug pushers instead of focusing on the kingpins. Does U.S. News and World Report rank a college higher for classes with under 20 students? Schedule seminars with a maximum of 19. (My example, not Muller’s.) Teach to the MCAS (unless, like Marty, you decide that’s hopeless and just quit). Buff the numbers.
You know the drill. And if you need to learn it to succeed – or not be judged a failure – you’ll learn it.
Studies show that “pay for performance” often doesn’t work. Metric advocates ignore these and call for more studies. In Muller’s words, “Metric fixation, which aspires to imitate science, too often resembles faith.”
Muller argues with balance and nuance. He affirms that objective measurement has helped sweep away old dogmas no one had ever tested and culled markedly substandard teachers. But he shows that over the past 30 years just counting what you know how to count, counting things that cannot be counted, and privileging belief over disconfirming evidence has conferred on metrics “elements of a cult,” whose baleful effects doctors and others toiling in their professional vineyards know too well.
Faith in metrics will wane and its cult will pass away, though likely well after we have done so ourselves. At some point, so-called situated knowledge – what people who actually do something know – will again be valued.
In the meantime, please rate this column highly (give it a 6 on a scale of 1-5), and confirm that there are no barriers to your implementing its wisdom, which comes unsullied by any financial conflicts of interest.
And check out Muller’s book. You have nothing to lose but your chains.
Measurement without meaning is tyranny!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Fungal failure
Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”
“How’s it going?” I asked.
Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”
I too, dear colleagues, have had a life’s ambition, secret until right now:
Alas, like Ed’s, my work is not yet done.
I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.
1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.
2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.
3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.
4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.
5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.
6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!
7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.
8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.
9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.
10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?
And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.
In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.
Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”
I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.
Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.
But then, there always is.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”
“How’s it going?” I asked.
Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”
I too, dear colleagues, have had a life’s ambition, secret until right now:
Alas, like Ed’s, my work is not yet done.
I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.
1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.
2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.
3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.
4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.
5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.
6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!
7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.
8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.
9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.
10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?
And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.
In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.
Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”
I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.
Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.
But then, there always is.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Two months ago I met Ed, still working at age 71. “My life’s ambition,” he said, “has been to help high school science teachers do their jobs better.”
“How’s it going?” I asked.
Ed sighed. “I’m still at it,” he said. “Let’s just say we’re not there yet.”
I too, dear colleagues, have had a life’s ambition, secret until right now:
Alas, like Ed’s, my work is not yet done.
I get reminders of this all the time, but last week the evidence got so overwhelming that I had to take a breath to settle down. And a nip. Ten cases. In 24 hours.
1. A 66-year-old woman energetically smeared econazole cream twice daily for weeks for an itchy, lichenified rash on both dorsal feet and ankles. Switched to betamethasone. Cleared in 5 days.
2. A 48-year-old woman with scaly patches on both legs. No response to terbinafine cream, then to ketoconazole cream, then to oral fluconazole. Cleared promptly on triamcinolone.
3. A 26-year-old with an erosive vulvar rash lasting month, unresponsive to Nystatin. After 5 days on a steroid, it was gone.
4. A 45-year-old man with lots of dermatoheliosis and idiopathic guttate hypomelanosis on arms and legs. No luck with topical selenium sulfide for tinea versicolor.
5. A 42-year-old nurse treated for weeks with topical antifungals. She came in with globs of fungus cream sealed in with Tegaderm (to prevent spread). Her roommates wanted to cancel her lease. Cleared of both rash and Tegaderm in 1 week. Now allowed to touch doorknobs.
6. A 27-year-old man with 8 weeks of lichenified patches all over his torso. Antifungal creams not working. Steroids do!
7. A 25-year-old recent émigré from India, where he was treated for his itchy groin rash with a succession of antifungal creams. He cannot sleep. (Imagine the plane trip from Delhi!) Has lichenified inguinal folds and scrotum. Cleared in 1 week with a topical steroid.
8. A 22-year-old woman with widespread atopic dermatitis. No response to antifungals. She had a rash at age 2 that was called “allergy to shampoo.” Clears promptly on a steroid.
9. A 22-year-old man being treated for a scaly, bilateral periocular rash with oral cephalexin. Clears promptly on a weak topical steroid.
10. A 29-year-old woman who has been suffering for months with “sensitivity” of her vulvar skin that has been diagnosed and treated as “a yeast infection,” in the absence of any rash or discharge. Her only visible finding is inverse psoriasis in the gluteal cleft. Guess what clears her up?
And so it goes, and so it has gone, week after week, year after year, decade after decade. Medicine scales Olympus: genomics, immunotherapy, stereotactic surgery. Meantime, the it’s-not-a-fungus problem seems impervious to both education and even to daily observation as obvious as it is ineffective: If a supposed fungus does not respond to antifungal treatment, then it must be a very bad fungus. If it doesn’t respond to yet another antifungal cream, then it must be terrible fungus. Reconsidering that it may not be a fungus at all seems to demand a mental paradigm shift whose achievement will have to await a more discerning generation.
In the meantime, patients not only don’t get better, but they feel defiled and dirty. They avoid human contact, intimate and otherwise, and do a lot of superfluous and expensive cleaning of house and wardrobe. If you doubt this, ask them. If you think I overstate, spend a day with me.
Early in my career I inherited the once-yearly dermatology slot at Medical Grand Rounds at the local community hospital. I spoke about cutaneous fungus, with emphasis on the fact that lots of round rashes are nummular eczema rather than fungus, as well as what it means to patients to be told they are “fungal.”
I didn’t get much direct feedback, but the chief of medicine sprang into action. He canceled the dermatology slot. Not medical enough, I guess.
Ed tells me that many high school science teachers don’t know much science. They teach it because they thought they might like to, or because there was an opening. After Ed hangs up his cleats, there will be plenty of his work left to be done.
But then, there always is.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
An iPledge Halloween
It was a dark and stormy night.
OK, it was a warm and sunny afternoon. But Halloween was approaching. Strange things happen. Plus, the patient’s name was Ichabod ...
OK, his name was Jerry. Jerry came to Boston from Chula Taco, Calif., to study at CIT, the famed Boston Chipotle Institute of Technology. He’d finished 4 months of isotretinoin and needed one more.
I asked him to call iPledge to request a transfer to me. He called back later to say that This seemed odd, since his pills had only run out 3 days before.
Having confirmed his name, address, telephone number, and the last four digits of his social security number, I tried enrolling him on iPledge at 5:30 p.m. (Cue: thunder and lightning), expecting to get a request for an override code. Instead the screen just asked for his iPledge number (you have to use the old one, you know). I called iPledge (my favorite pastime), identified myself by the usual means (Full name. iPledge ID number. Date of personal significance. Office telephone. Thank you. How can I help you?).
I explained my dilemma. The representative asked that I verify Jerry’s identity. I gave her his name, date of birth, and the last four of his social.
“We have his name and date of birth,” she said, “but the social security digits don’t match.” She asked for his phone number, but his Boston number didn’t match what she had. “Do you have his address?” she asked. I did not, since he’d given me his Boston address, not his California one.
I left her on hold and called Jerry on my cell. He confirmed that the social security digits he’d given me were correct. He gave me his mother’s cell phone number, but that also turned out not to be what iPledge had on file.
“What other identifying information can I give you?” I asked the iPledge rep. “How about his home address?” she said. Back to my cell: “Jerry, what’s your home address?” “It’s 2470 Chalupa Drive, Chula Taco, California 9090909-090909,” he said.
I repeated that to the iPledge representative. “Please hold a moment,” she said.
She was back. “The street address is correct,” she said, “The ZIP is correct. But the town is wrong.”
The town is wrong? If Jerry didn’t know either the last four of his social or his town, how did he get Amazon deliveries? Was this identity theft by an Accutane seeker? Maybe Jerry was really a Russian spy with dry lips posing as an acne patient! (Cue: screeches, howls, more thunder.)
“Can you tell me which town you have listed for him?” I asked iPledge.
“No,” she said, “because you haven’t identified him properly yet,” (emphasis added).
Back to the cell: “Jerry, are you sure you know what town you live in?” He insisted he did. (But then, so would a spy, wouldn’t he?)
In near despair, I returned to the iPledge rep. “I really want to get this patient his medication, “I said. “And I really want to go home. Can you help either of us?”
“Let me get my supervisor,” she said. “This may take a few minutes.” I hung up on Jerry and, in a blaze of multitasking, filled out three Prior Authorization forms for clindamycin gel.
“I found your patient,” said the rep, returning at last. “Not only that, I was able to reregister him in the iPledge program. Want to know his iPledge number?
Of course!
“Now that he’s registered,” I said, “could you give me the name of the town you have him listed as living in on Chalupa Drive?”
“Sure,” she said, “We have him in Rancho Carmen Miranda. Can help you with anything else today?”
“No, thanks ...”
“Would you be willing to take a 2-minute survey ...?”
“No, but thank you very much!” I said, hanging up in triumph. (Cue: sunshine, violins.)
Back to the cell: “Jerry, you’re in! Here’s your iPledge number.”
“Thanks, Doc.”
“By the way, Jerry, iPledge has you living in the town of Rancho Carmen Miranda. Do you live there?”
“No,” said Jerry. “I don’t.”
“Well, Jerry, for 1 more month, for federal purposes, you do!”
I’m sure there’s a good explanation for all this. I just don’t want to know it. Just pass the candy corn.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
It was a dark and stormy night.
OK, it was a warm and sunny afternoon. But Halloween was approaching. Strange things happen. Plus, the patient’s name was Ichabod ...
OK, his name was Jerry. Jerry came to Boston from Chula Taco, Calif., to study at CIT, the famed Boston Chipotle Institute of Technology. He’d finished 4 months of isotretinoin and needed one more.
I asked him to call iPledge to request a transfer to me. He called back later to say that This seemed odd, since his pills had only run out 3 days before.
Having confirmed his name, address, telephone number, and the last four digits of his social security number, I tried enrolling him on iPledge at 5:30 p.m. (Cue: thunder and lightning), expecting to get a request for an override code. Instead the screen just asked for his iPledge number (you have to use the old one, you know). I called iPledge (my favorite pastime), identified myself by the usual means (Full name. iPledge ID number. Date of personal significance. Office telephone. Thank you. How can I help you?).
I explained my dilemma. The representative asked that I verify Jerry’s identity. I gave her his name, date of birth, and the last four of his social.
“We have his name and date of birth,” she said, “but the social security digits don’t match.” She asked for his phone number, but his Boston number didn’t match what she had. “Do you have his address?” she asked. I did not, since he’d given me his Boston address, not his California one.
I left her on hold and called Jerry on my cell. He confirmed that the social security digits he’d given me were correct. He gave me his mother’s cell phone number, but that also turned out not to be what iPledge had on file.
“What other identifying information can I give you?” I asked the iPledge rep. “How about his home address?” she said. Back to my cell: “Jerry, what’s your home address?” “It’s 2470 Chalupa Drive, Chula Taco, California 9090909-090909,” he said.
I repeated that to the iPledge representative. “Please hold a moment,” she said.
She was back. “The street address is correct,” she said, “The ZIP is correct. But the town is wrong.”
The town is wrong? If Jerry didn’t know either the last four of his social or his town, how did he get Amazon deliveries? Was this identity theft by an Accutane seeker? Maybe Jerry was really a Russian spy with dry lips posing as an acne patient! (Cue: screeches, howls, more thunder.)
“Can you tell me which town you have listed for him?” I asked iPledge.
“No,” she said, “because you haven’t identified him properly yet,” (emphasis added).
Back to the cell: “Jerry, are you sure you know what town you live in?” He insisted he did. (But then, so would a spy, wouldn’t he?)
In near despair, I returned to the iPledge rep. “I really want to get this patient his medication, “I said. “And I really want to go home. Can you help either of us?”
“Let me get my supervisor,” she said. “This may take a few minutes.” I hung up on Jerry and, in a blaze of multitasking, filled out three Prior Authorization forms for clindamycin gel.
“I found your patient,” said the rep, returning at last. “Not only that, I was able to reregister him in the iPledge program. Want to know his iPledge number?
Of course!
“Now that he’s registered,” I said, “could you give me the name of the town you have him listed as living in on Chalupa Drive?”
“Sure,” she said, “We have him in Rancho Carmen Miranda. Can help you with anything else today?”
“No, thanks ...”
“Would you be willing to take a 2-minute survey ...?”
“No, but thank you very much!” I said, hanging up in triumph. (Cue: sunshine, violins.)
Back to the cell: “Jerry, you’re in! Here’s your iPledge number.”
“Thanks, Doc.”
“By the way, Jerry, iPledge has you living in the town of Rancho Carmen Miranda. Do you live there?”
“No,” said Jerry. “I don’t.”
“Well, Jerry, for 1 more month, for federal purposes, you do!”
I’m sure there’s a good explanation for all this. I just don’t want to know it. Just pass the candy corn.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
It was a dark and stormy night.
OK, it was a warm and sunny afternoon. But Halloween was approaching. Strange things happen. Plus, the patient’s name was Ichabod ...
OK, his name was Jerry. Jerry came to Boston from Chula Taco, Calif., to study at CIT, the famed Boston Chipotle Institute of Technology. He’d finished 4 months of isotretinoin and needed one more.
I asked him to call iPledge to request a transfer to me. He called back later to say that This seemed odd, since his pills had only run out 3 days before.
Having confirmed his name, address, telephone number, and the last four digits of his social security number, I tried enrolling him on iPledge at 5:30 p.m. (Cue: thunder and lightning), expecting to get a request for an override code. Instead the screen just asked for his iPledge number (you have to use the old one, you know). I called iPledge (my favorite pastime), identified myself by the usual means (Full name. iPledge ID number. Date of personal significance. Office telephone. Thank you. How can I help you?).
I explained my dilemma. The representative asked that I verify Jerry’s identity. I gave her his name, date of birth, and the last four of his social.
“We have his name and date of birth,” she said, “but the social security digits don’t match.” She asked for his phone number, but his Boston number didn’t match what she had. “Do you have his address?” she asked. I did not, since he’d given me his Boston address, not his California one.
I left her on hold and called Jerry on my cell. He confirmed that the social security digits he’d given me were correct. He gave me his mother’s cell phone number, but that also turned out not to be what iPledge had on file.
“What other identifying information can I give you?” I asked the iPledge rep. “How about his home address?” she said. Back to my cell: “Jerry, what’s your home address?” “It’s 2470 Chalupa Drive, Chula Taco, California 9090909-090909,” he said.
I repeated that to the iPledge representative. “Please hold a moment,” she said.
She was back. “The street address is correct,” she said, “The ZIP is correct. But the town is wrong.”
The town is wrong? If Jerry didn’t know either the last four of his social or his town, how did he get Amazon deliveries? Was this identity theft by an Accutane seeker? Maybe Jerry was really a Russian spy with dry lips posing as an acne patient! (Cue: screeches, howls, more thunder.)
“Can you tell me which town you have listed for him?” I asked iPledge.
“No,” she said, “because you haven’t identified him properly yet,” (emphasis added).
Back to the cell: “Jerry, are you sure you know what town you live in?” He insisted he did. (But then, so would a spy, wouldn’t he?)
In near despair, I returned to the iPledge rep. “I really want to get this patient his medication, “I said. “And I really want to go home. Can you help either of us?”
“Let me get my supervisor,” she said. “This may take a few minutes.” I hung up on Jerry and, in a blaze of multitasking, filled out three Prior Authorization forms for clindamycin gel.
“I found your patient,” said the rep, returning at last. “Not only that, I was able to reregister him in the iPledge program. Want to know his iPledge number?
Of course!
“Now that he’s registered,” I said, “could you give me the name of the town you have him listed as living in on Chalupa Drive?”
“Sure,” she said, “We have him in Rancho Carmen Miranda. Can help you with anything else today?”
“No, thanks ...”
“Would you be willing to take a 2-minute survey ...?”
“No, but thank you very much!” I said, hanging up in triumph. (Cue: sunshine, violins.)
Back to the cell: “Jerry, you’re in! Here’s your iPledge number.”
“Thanks, Doc.”
“By the way, Jerry, iPledge has you living in the town of Rancho Carmen Miranda. Do you live there?”
“No,” said Jerry. “I don’t.”
“Well, Jerry, for 1 more month, for federal purposes, you do!”
I’m sure there’s a good explanation for all this. I just don’t want to know it. Just pass the candy corn.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Cancer and conference calls
You notice I said, “Ask the question.” I can always ask. I just can’t always answer.
Harriet listed her Chief Complaint as “psoriasis on the scalp.”
“My hairdresser says I have psoriasis,” she said.
I took a look. “You do,” I said. “Just one spot, though. Should be easy to control.”
I then ran through the list of what generally bothers people about scalp psoriasis. “It may come back now and then,” I said, “but you don’t have much of it and you haven’t had it long, so it shouldn’t take much effort to keep it under control. Psoriasis doesn’t cause permanent hair loss,” I added. “And you can color and condition your hair any way you want.”
Harriet smiled. That was what she wanted to hear. But it wasn’t all she wanted to hear.
“Why don’t I look you over completely?” I suggested. Harriet agreed. I found only lentigines and seborrheic keratoses all over, and I told her so.
“That’s wonderful,” said Harriet. “Just one more thing.”
“Sure.”
“That psoriasis on my head. It wouldn’t be cancer, would it?”
I opened my mouth to respond, but nothing came out. Sure, patients worry that anything they don’t understand might be cancer. But that’s to start with, not after a whole conversation about psoriasis. Right?
Maybe not.
“Not cancer,” I said. “Just some local inflammation.” Harriet was happy. I was perplexed. There’s always something new about patients to puzzle over.
Which I did for about 2 hours, until that puzzle was muscled out by another. I walked in to meet a very cheery Rory, who was punching his smartphone screen. “Wouldn’t you know it?” he said with a smile. “The same thing happened last time I came here. You walked in just as I was about to start a conference call.”
I thought of several responses, none of them appropriate.
“Last time you cauterized some of these milia thingies on my face,” said Rory. “I was hoping you could do that again.”
I peered at his face. “Sure,” I said, “if you want me to.”
“Just a sec,” said Rory, peering down at his phone. I assumed he was logging off the conference call.
“OK,” he said. “Go ahead.”
I revved up my Hyfrecator, which started to buzz.
“Wait, can they hear that?” Rory asked.
“Can who hear ... ?”
“This is Rory Stiefel,” he spoke into his phone. “Glad we could meet today. I wanted to talk to all of you about our plans to expand our network services into your Upper Midwestern territory.”
“Hold on,” I said (to myself), “You want me to desiccate your face while you’re expanding your network into the Upper Midwest??!!”
Rory motioned for me to continue. “Sure,” he said to his phone, “We can be up and running by the first of next month, no problem.” Apparently, the hum of the Hyfrecator wasn’t interrupting negotiations.
So I buzzed away, while Rory’s interlocutors responded with apparent enthusiasm. By the time he turned his other cheek, I figured he had occupied Minnesota.
“Did you get all the thingies?” Rory stage-whispered.
I nodded.
“Great!” he said, then turned back to his phone. “Well, this was a great meeting,” he said. “I’m glad we’re ready to go live. Talk to you guys next week to firm up logistics.” He punched the screen to sever the connection.
“Thanks for being so efficient,” he said, this time to me.
“No problem,” I said, now-silent Hyfrecator in hand.
“You’re sure you got them all?”
“I handed him a mirror. “Yes,” I said. “I got them all.”
“Well that’s terrific,” he said, jumping off the exam table and heading for the door. “Always a pleasure. See you next time!”
I don’t know exactly what he does, but Rory is one awesome multitasker.
As for me, I just have to consult the CPT code book to find the right designation for “Cautery of benign lesions during a corporate conference call, second episode.”
Any help, dear colleagues, with people or coding, will be appreciated.
I can always ask ...
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
You notice I said, “Ask the question.” I can always ask. I just can’t always answer.
Harriet listed her Chief Complaint as “psoriasis on the scalp.”
“My hairdresser says I have psoriasis,” she said.
I took a look. “You do,” I said. “Just one spot, though. Should be easy to control.”
I then ran through the list of what generally bothers people about scalp psoriasis. “It may come back now and then,” I said, “but you don’t have much of it and you haven’t had it long, so it shouldn’t take much effort to keep it under control. Psoriasis doesn’t cause permanent hair loss,” I added. “And you can color and condition your hair any way you want.”
Harriet smiled. That was what she wanted to hear. But it wasn’t all she wanted to hear.
“Why don’t I look you over completely?” I suggested. Harriet agreed. I found only lentigines and seborrheic keratoses all over, and I told her so.
“That’s wonderful,” said Harriet. “Just one more thing.”
“Sure.”
“That psoriasis on my head. It wouldn’t be cancer, would it?”
I opened my mouth to respond, but nothing came out. Sure, patients worry that anything they don’t understand might be cancer. But that’s to start with, not after a whole conversation about psoriasis. Right?
Maybe not.
“Not cancer,” I said. “Just some local inflammation.” Harriet was happy. I was perplexed. There’s always something new about patients to puzzle over.
Which I did for about 2 hours, until that puzzle was muscled out by another. I walked in to meet a very cheery Rory, who was punching his smartphone screen. “Wouldn’t you know it?” he said with a smile. “The same thing happened last time I came here. You walked in just as I was about to start a conference call.”
I thought of several responses, none of them appropriate.
“Last time you cauterized some of these milia thingies on my face,” said Rory. “I was hoping you could do that again.”
I peered at his face. “Sure,” I said, “if you want me to.”
“Just a sec,” said Rory, peering down at his phone. I assumed he was logging off the conference call.
“OK,” he said. “Go ahead.”
I revved up my Hyfrecator, which started to buzz.
“Wait, can they hear that?” Rory asked.
“Can who hear ... ?”
“This is Rory Stiefel,” he spoke into his phone. “Glad we could meet today. I wanted to talk to all of you about our plans to expand our network services into your Upper Midwestern territory.”
“Hold on,” I said (to myself), “You want me to desiccate your face while you’re expanding your network into the Upper Midwest??!!”
Rory motioned for me to continue. “Sure,” he said to his phone, “We can be up and running by the first of next month, no problem.” Apparently, the hum of the Hyfrecator wasn’t interrupting negotiations.
So I buzzed away, while Rory’s interlocutors responded with apparent enthusiasm. By the time he turned his other cheek, I figured he had occupied Minnesota.
“Did you get all the thingies?” Rory stage-whispered.
I nodded.
“Great!” he said, then turned back to his phone. “Well, this was a great meeting,” he said. “I’m glad we’re ready to go live. Talk to you guys next week to firm up logistics.” He punched the screen to sever the connection.
“Thanks for being so efficient,” he said, this time to me.
“No problem,” I said, now-silent Hyfrecator in hand.
“You’re sure you got them all?”
“I handed him a mirror. “Yes,” I said. “I got them all.”
“Well that’s terrific,” he said, jumping off the exam table and heading for the door. “Always a pleasure. See you next time!”
I don’t know exactly what he does, but Rory is one awesome multitasker.
As for me, I just have to consult the CPT code book to find the right designation for “Cautery of benign lesions during a corporate conference call, second episode.”
Any help, dear colleagues, with people or coding, will be appreciated.
I can always ask ...
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
You notice I said, “Ask the question.” I can always ask. I just can’t always answer.
Harriet listed her Chief Complaint as “psoriasis on the scalp.”
“My hairdresser says I have psoriasis,” she said.
I took a look. “You do,” I said. “Just one spot, though. Should be easy to control.”
I then ran through the list of what generally bothers people about scalp psoriasis. “It may come back now and then,” I said, “but you don’t have much of it and you haven’t had it long, so it shouldn’t take much effort to keep it under control. Psoriasis doesn’t cause permanent hair loss,” I added. “And you can color and condition your hair any way you want.”
Harriet smiled. That was what she wanted to hear. But it wasn’t all she wanted to hear.
“Why don’t I look you over completely?” I suggested. Harriet agreed. I found only lentigines and seborrheic keratoses all over, and I told her so.
“That’s wonderful,” said Harriet. “Just one more thing.”
“Sure.”
“That psoriasis on my head. It wouldn’t be cancer, would it?”
I opened my mouth to respond, but nothing came out. Sure, patients worry that anything they don’t understand might be cancer. But that’s to start with, not after a whole conversation about psoriasis. Right?
Maybe not.
“Not cancer,” I said. “Just some local inflammation.” Harriet was happy. I was perplexed. There’s always something new about patients to puzzle over.
Which I did for about 2 hours, until that puzzle was muscled out by another. I walked in to meet a very cheery Rory, who was punching his smartphone screen. “Wouldn’t you know it?” he said with a smile. “The same thing happened last time I came here. You walked in just as I was about to start a conference call.”
I thought of several responses, none of them appropriate.
“Last time you cauterized some of these milia thingies on my face,” said Rory. “I was hoping you could do that again.”
I peered at his face. “Sure,” I said, “if you want me to.”
“Just a sec,” said Rory, peering down at his phone. I assumed he was logging off the conference call.
“OK,” he said. “Go ahead.”
I revved up my Hyfrecator, which started to buzz.
“Wait, can they hear that?” Rory asked.
“Can who hear ... ?”
“This is Rory Stiefel,” he spoke into his phone. “Glad we could meet today. I wanted to talk to all of you about our plans to expand our network services into your Upper Midwestern territory.”
“Hold on,” I said (to myself), “You want me to desiccate your face while you’re expanding your network into the Upper Midwest??!!”
Rory motioned for me to continue. “Sure,” he said to his phone, “We can be up and running by the first of next month, no problem.” Apparently, the hum of the Hyfrecator wasn’t interrupting negotiations.
So I buzzed away, while Rory’s interlocutors responded with apparent enthusiasm. By the time he turned his other cheek, I figured he had occupied Minnesota.
“Did you get all the thingies?” Rory stage-whispered.
I nodded.
“Great!” he said, then turned back to his phone. “Well, this was a great meeting,” he said. “I’m glad we’re ready to go live. Talk to you guys next week to firm up logistics.” He punched the screen to sever the connection.
“Thanks for being so efficient,” he said, this time to me.
“No problem,” I said, now-silent Hyfrecator in hand.
“You’re sure you got them all?”
“I handed him a mirror. “Yes,” I said. “I got them all.”
“Well that’s terrific,” he said, jumping off the exam table and heading for the door. “Always a pleasure. See you next time!”
I don’t know exactly what he does, but Rory is one awesome multitasker.
As for me, I just have to consult the CPT code book to find the right designation for “Cautery of benign lesions during a corporate conference call, second episode.”
Any help, dear colleagues, with people or coding, will be appreciated.
I can always ask ...
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Put the cash in the shoebox
Even when I was training back in the Pleistocene era, old Doc Greenberg was a throwback. During my pediatric residency, I accompanied him for a day to his office in the Parkchester neighborhood of the Bronx. With no secretary or office staff, Greenberg just processed patients himself. After he examined their kids, each mother handed him a $10 bill, which he stuffed into a box in his desk drawer. No records, no accountability, no payroll taxes ... Those were the days, bygone even then.
What prompted this reverie was recollecting a conversation I had quite some time ago with Stan, a retired drug rep of the old school: terrible combover, rumpled suit, beat-up briefcase. Stan regaled me with tales of derms he had called on many years before.
“Ed Gillooly down in Scituate used to charge $7 a visit,” Stan told me. “I asked him why so little – this was back in the ’60s – and he said, ‘Phil Gluckstern charges 20 bucks a visit in his fancy downtown office, but he has to spend half an hour with a patient. I just see ’em, diagnose ’em, prescribe for ’em, and they’re out the door.’
“Dermatology wasn’t the high-class deal it’s gotten to be,” said Stan. “It was sort of out there. Every doctor had his own special lotion or concoction, his calling card. The local pharmacist knew how to mix it up, but of course would never share the secret formula.
“Nobody referred anybody to another doctor if they could help it. They were terrified they’d never see the patient back.
“It was all cash. There was no Medicare, no third parties. The money would get put into a shoebox, which would go into the doctor’s closet. A lot of offices were in the doc’s house. Sometimes a babysitter would go through the closet, and wouldn’t you know, but the next time the doc’s wife looked, last week’s receipts were gone.
“Secretaries? Doctors wouldn’t bother with them. Sometimes their mothers or wives, who knew as little about office management as they did, would come in and mess things up.”
This observation resonated. Almost 40 years ago, I took over what was left of Al Shipman’s practice when the old-timer (as he seemed to me then) retired to Florida.
Al’s office was a converted garage. Rummaging through a closet, he offered me ancient samples of sulfur-resorcinol acne lotions. Then he pulled out a well-thumbed Merck Manual from the 1930s, with the front cover missing. “I always found this useful,” he said. “You can have it if you want.” I politely declined.
“You young fellas spend money like it’s going out of style,” said Al. “You all think you need secretaries. Never had one!”
My reverie done, I focused back on Stan, who was saying, “Doctors in those days did pretty much everything themselves.
“For instance, Jack Vallis had about thirty chairs in his waiting room. Whenever Jack came out to call the next patient, everybody got up and moved over one chair.
“Once – I swear this actually happened – a patient came in with a severe laceration on his wrist; his damned arm was dangling half-off. But he had to sit down in the last chair and take his turn, same as anybody else.
“I used to call on non-derms too. We carried cortisone creams and antifungal creams, and they used to stop and ask me, ‘Now Stan, I put this fungus cream on the fungus and the cortisone cream on the eczema, am I right?’”
Some things indeed don’t change.
I guess it’s just human nature to pine for When patients (or their biopsy specimens) could go to any lab you sent them to.
Ah, wasn’t that the life? When patients paid you 10 bucks in cash and you stuffed it in your shoebox? When if they didn’t have cash, they sent you a roast turkey on Thanksgiving, or a dozen eggs, or maybe nothing at all?
If you’re the sentimental sort, you can wax nostalgic about those good old days if you want. But you’ll forgive me if I don’t join you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Even when I was training back in the Pleistocene era, old Doc Greenberg was a throwback. During my pediatric residency, I accompanied him for a day to his office in the Parkchester neighborhood of the Bronx. With no secretary or office staff, Greenberg just processed patients himself. After he examined their kids, each mother handed him a $10 bill, which he stuffed into a box in his desk drawer. No records, no accountability, no payroll taxes ... Those were the days, bygone even then.
What prompted this reverie was recollecting a conversation I had quite some time ago with Stan, a retired drug rep of the old school: terrible combover, rumpled suit, beat-up briefcase. Stan regaled me with tales of derms he had called on many years before.
“Ed Gillooly down in Scituate used to charge $7 a visit,” Stan told me. “I asked him why so little – this was back in the ’60s – and he said, ‘Phil Gluckstern charges 20 bucks a visit in his fancy downtown office, but he has to spend half an hour with a patient. I just see ’em, diagnose ’em, prescribe for ’em, and they’re out the door.’
“Dermatology wasn’t the high-class deal it’s gotten to be,” said Stan. “It was sort of out there. Every doctor had his own special lotion or concoction, his calling card. The local pharmacist knew how to mix it up, but of course would never share the secret formula.
“Nobody referred anybody to another doctor if they could help it. They were terrified they’d never see the patient back.
“It was all cash. There was no Medicare, no third parties. The money would get put into a shoebox, which would go into the doctor’s closet. A lot of offices were in the doc’s house. Sometimes a babysitter would go through the closet, and wouldn’t you know, but the next time the doc’s wife looked, last week’s receipts were gone.
“Secretaries? Doctors wouldn’t bother with them. Sometimes their mothers or wives, who knew as little about office management as they did, would come in and mess things up.”
This observation resonated. Almost 40 years ago, I took over what was left of Al Shipman’s practice when the old-timer (as he seemed to me then) retired to Florida.
Al’s office was a converted garage. Rummaging through a closet, he offered me ancient samples of sulfur-resorcinol acne lotions. Then he pulled out a well-thumbed Merck Manual from the 1930s, with the front cover missing. “I always found this useful,” he said. “You can have it if you want.” I politely declined.
“You young fellas spend money like it’s going out of style,” said Al. “You all think you need secretaries. Never had one!”
My reverie done, I focused back on Stan, who was saying, “Doctors in those days did pretty much everything themselves.
“For instance, Jack Vallis had about thirty chairs in his waiting room. Whenever Jack came out to call the next patient, everybody got up and moved over one chair.
“Once – I swear this actually happened – a patient came in with a severe laceration on his wrist; his damned arm was dangling half-off. But he had to sit down in the last chair and take his turn, same as anybody else.
“I used to call on non-derms too. We carried cortisone creams and antifungal creams, and they used to stop and ask me, ‘Now Stan, I put this fungus cream on the fungus and the cortisone cream on the eczema, am I right?’”
Some things indeed don’t change.
I guess it’s just human nature to pine for When patients (or their biopsy specimens) could go to any lab you sent them to.
Ah, wasn’t that the life? When patients paid you 10 bucks in cash and you stuffed it in your shoebox? When if they didn’t have cash, they sent you a roast turkey on Thanksgiving, or a dozen eggs, or maybe nothing at all?
If you’re the sentimental sort, you can wax nostalgic about those good old days if you want. But you’ll forgive me if I don’t join you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Even when I was training back in the Pleistocene era, old Doc Greenberg was a throwback. During my pediatric residency, I accompanied him for a day to his office in the Parkchester neighborhood of the Bronx. With no secretary or office staff, Greenberg just processed patients himself. After he examined their kids, each mother handed him a $10 bill, which he stuffed into a box in his desk drawer. No records, no accountability, no payroll taxes ... Those were the days, bygone even then.
What prompted this reverie was recollecting a conversation I had quite some time ago with Stan, a retired drug rep of the old school: terrible combover, rumpled suit, beat-up briefcase. Stan regaled me with tales of derms he had called on many years before.
“Ed Gillooly down in Scituate used to charge $7 a visit,” Stan told me. “I asked him why so little – this was back in the ’60s – and he said, ‘Phil Gluckstern charges 20 bucks a visit in his fancy downtown office, but he has to spend half an hour with a patient. I just see ’em, diagnose ’em, prescribe for ’em, and they’re out the door.’
“Dermatology wasn’t the high-class deal it’s gotten to be,” said Stan. “It was sort of out there. Every doctor had his own special lotion or concoction, his calling card. The local pharmacist knew how to mix it up, but of course would never share the secret formula.
“Nobody referred anybody to another doctor if they could help it. They were terrified they’d never see the patient back.
“It was all cash. There was no Medicare, no third parties. The money would get put into a shoebox, which would go into the doctor’s closet. A lot of offices were in the doc’s house. Sometimes a babysitter would go through the closet, and wouldn’t you know, but the next time the doc’s wife looked, last week’s receipts were gone.
“Secretaries? Doctors wouldn’t bother with them. Sometimes their mothers or wives, who knew as little about office management as they did, would come in and mess things up.”
This observation resonated. Almost 40 years ago, I took over what was left of Al Shipman’s practice when the old-timer (as he seemed to me then) retired to Florida.
Al’s office was a converted garage. Rummaging through a closet, he offered me ancient samples of sulfur-resorcinol acne lotions. Then he pulled out a well-thumbed Merck Manual from the 1930s, with the front cover missing. “I always found this useful,” he said. “You can have it if you want.” I politely declined.
“You young fellas spend money like it’s going out of style,” said Al. “You all think you need secretaries. Never had one!”
My reverie done, I focused back on Stan, who was saying, “Doctors in those days did pretty much everything themselves.
“For instance, Jack Vallis had about thirty chairs in his waiting room. Whenever Jack came out to call the next patient, everybody got up and moved over one chair.
“Once – I swear this actually happened – a patient came in with a severe laceration on his wrist; his damned arm was dangling half-off. But he had to sit down in the last chair and take his turn, same as anybody else.
“I used to call on non-derms too. We carried cortisone creams and antifungal creams, and they used to stop and ask me, ‘Now Stan, I put this fungus cream on the fungus and the cortisone cream on the eczema, am I right?’”
Some things indeed don’t change.
I guess it’s just human nature to pine for When patients (or their biopsy specimens) could go to any lab you sent them to.
Ah, wasn’t that the life? When patients paid you 10 bucks in cash and you stuffed it in your shoebox? When if they didn’t have cash, they sent you a roast turkey on Thanksgiving, or a dozen eggs, or maybe nothing at all?
If you’re the sentimental sort, you can wax nostalgic about those good old days if you want. But you’ll forgive me if I don’t join you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Professional psychology
, the ability to figure out how to get people to accept what you’re trying to do for them.
Expertise and psychology: Every profession needs both, including our own. Over my years in practice, I’ve met people in many walks of life who develop the same combination. Here are some favorites:
1. Wedding planners
Venues, décor, dresses, floral arrangements, caterers, bands. Wedding planners must know about all of these. And that’s just the start.
Weddings make everyone a bit crazy, or more than a bit. There are parents trying not to let go, children trying to pull away (a Destination Wedding in Patagonia – perfect – none of the family can come!), cultural and taste gaps between the sides (tipplers from Tinseltown and teetotalers from Tupelo), culling the guest list (see Patagonia). Every wedding planner I’ve met could write a book, but won’t. Legal fees would be too high.
Given all this turmoil, some wedding planners might advise elopement and put themselves out of business. No fear of that happening.
2. Event planners
See Wedding Planners, only add: arbitrary and capricious bosses, incompetent implementers, acts of God, acts of man, and everything that goes wrong when there are too many moving parts. One close friend who organizes professional conventions says that every year one attendee posts this complaint on the message board: “Why is there no Diet Mountain Dew?!!!”
3. Dressmakers
Again, see Wedding Planners. Knowing how to design, create, and fit a dress demands a set of skills that earns my admiration and respect. Knowing how to deal with the people who are going to wear the dresses deserves not respect but awe. Even if I knew how to sew, I wouldn’t last a week in this business.
4. Financial planners
Every financial planner I meet describes what they do as “mostly psychology.” Of course, they need to recommend investments that suit the age, life status, and plans of their clients. That’s the easy part.
“When the market is dropping,” says Phil, “people call to scream that they’re losing their shirt. When the market is going up, they call to scream that they’re not making out as well as their friends claim they are.
“Either way, I just hold the phone far enough away from my ear to save my hearing until they’re done venting. Then I try to calm them down and assure them that investing is a long game, and over time they’ll do better staying the course we agreed on than jumping around with every market swing, up or down.”
“Do they listen?”
“Most of them. Eventually.”
4. Speakers’ booking agents
Matching clients with speakers can bring curious challenges. Celebrity speakers in particular may have unique requirements that the agents who book them must figure out and comply with. Or else.
For instance, one young man I met had to book a distinguished jurist. He needed to be picked up in a limo. The limo had to be a Bentley. And the Bentley had to be gray.
Well, excuse me.
5. Waiters
I think the favored term these days is “Servers.” Servers serve strangers. Some strangers are pleasant and courteous. Not all. Waiters mean to please, but to do that they have to put up with a lot. Always with a smile, of course.
Customers ask silly questions. (“What’s good here?”) Some don’t find the menu detailed enough. (“Can I have half of this and some of that, with the sauce on the side?”) They may find the food too hot. Or too cold. Or too spicy. Or too bland. After all that, they may tip a little. Or not.
But the server still has to ask, “Is everything satisfactory?”
6. Psychologists
Never mind.
7. Parking meter readers
Just kidding. Meter readers write parking tickets.
They know perfectly well that everyone knows exactly what they do. And they don’t care.
8. People who field complaints at call centers
Requirement: Patience, savvy, Xanax.
9. Dermatologists
You bet, in spades. I wrote a whole book on the subject. You can read it if you want to. If you disagree, don’t tell me.
I don’t need readers to disagree with me. I already have patients.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com .
, the ability to figure out how to get people to accept what you’re trying to do for them.
Expertise and psychology: Every profession needs both, including our own. Over my years in practice, I’ve met people in many walks of life who develop the same combination. Here are some favorites:
1. Wedding planners
Venues, décor, dresses, floral arrangements, caterers, bands. Wedding planners must know about all of these. And that’s just the start.
Weddings make everyone a bit crazy, or more than a bit. There are parents trying not to let go, children trying to pull away (a Destination Wedding in Patagonia – perfect – none of the family can come!), cultural and taste gaps between the sides (tipplers from Tinseltown and teetotalers from Tupelo), culling the guest list (see Patagonia). Every wedding planner I’ve met could write a book, but won’t. Legal fees would be too high.
Given all this turmoil, some wedding planners might advise elopement and put themselves out of business. No fear of that happening.
2. Event planners
See Wedding Planners, only add: arbitrary and capricious bosses, incompetent implementers, acts of God, acts of man, and everything that goes wrong when there are too many moving parts. One close friend who organizes professional conventions says that every year one attendee posts this complaint on the message board: “Why is there no Diet Mountain Dew?!!!”
3. Dressmakers
Again, see Wedding Planners. Knowing how to design, create, and fit a dress demands a set of skills that earns my admiration and respect. Knowing how to deal with the people who are going to wear the dresses deserves not respect but awe. Even if I knew how to sew, I wouldn’t last a week in this business.
4. Financial planners
Every financial planner I meet describes what they do as “mostly psychology.” Of course, they need to recommend investments that suit the age, life status, and plans of their clients. That’s the easy part.
“When the market is dropping,” says Phil, “people call to scream that they’re losing their shirt. When the market is going up, they call to scream that they’re not making out as well as their friends claim they are.
“Either way, I just hold the phone far enough away from my ear to save my hearing until they’re done venting. Then I try to calm them down and assure them that investing is a long game, and over time they’ll do better staying the course we agreed on than jumping around with every market swing, up or down.”
“Do they listen?”
“Most of them. Eventually.”
4. Speakers’ booking agents
Matching clients with speakers can bring curious challenges. Celebrity speakers in particular may have unique requirements that the agents who book them must figure out and comply with. Or else.
For instance, one young man I met had to book a distinguished jurist. He needed to be picked up in a limo. The limo had to be a Bentley. And the Bentley had to be gray.
Well, excuse me.
5. Waiters
I think the favored term these days is “Servers.” Servers serve strangers. Some strangers are pleasant and courteous. Not all. Waiters mean to please, but to do that they have to put up with a lot. Always with a smile, of course.
Customers ask silly questions. (“What’s good here?”) Some don’t find the menu detailed enough. (“Can I have half of this and some of that, with the sauce on the side?”) They may find the food too hot. Or too cold. Or too spicy. Or too bland. After all that, they may tip a little. Or not.
But the server still has to ask, “Is everything satisfactory?”
6. Psychologists
Never mind.
7. Parking meter readers
Just kidding. Meter readers write parking tickets.
They know perfectly well that everyone knows exactly what they do. And they don’t care.
8. People who field complaints at call centers
Requirement: Patience, savvy, Xanax.
9. Dermatologists
You bet, in spades. I wrote a whole book on the subject. You can read it if you want to. If you disagree, don’t tell me.
I don’t need readers to disagree with me. I already have patients.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com .
, the ability to figure out how to get people to accept what you’re trying to do for them.
Expertise and psychology: Every profession needs both, including our own. Over my years in practice, I’ve met people in many walks of life who develop the same combination. Here are some favorites:
1. Wedding planners
Venues, décor, dresses, floral arrangements, caterers, bands. Wedding planners must know about all of these. And that’s just the start.
Weddings make everyone a bit crazy, or more than a bit. There are parents trying not to let go, children trying to pull away (a Destination Wedding in Patagonia – perfect – none of the family can come!), cultural and taste gaps between the sides (tipplers from Tinseltown and teetotalers from Tupelo), culling the guest list (see Patagonia). Every wedding planner I’ve met could write a book, but won’t. Legal fees would be too high.
Given all this turmoil, some wedding planners might advise elopement and put themselves out of business. No fear of that happening.
2. Event planners
See Wedding Planners, only add: arbitrary and capricious bosses, incompetent implementers, acts of God, acts of man, and everything that goes wrong when there are too many moving parts. One close friend who organizes professional conventions says that every year one attendee posts this complaint on the message board: “Why is there no Diet Mountain Dew?!!!”
3. Dressmakers
Again, see Wedding Planners. Knowing how to design, create, and fit a dress demands a set of skills that earns my admiration and respect. Knowing how to deal with the people who are going to wear the dresses deserves not respect but awe. Even if I knew how to sew, I wouldn’t last a week in this business.
4. Financial planners
Every financial planner I meet describes what they do as “mostly psychology.” Of course, they need to recommend investments that suit the age, life status, and plans of their clients. That’s the easy part.
“When the market is dropping,” says Phil, “people call to scream that they’re losing their shirt. When the market is going up, they call to scream that they’re not making out as well as their friends claim they are.
“Either way, I just hold the phone far enough away from my ear to save my hearing until they’re done venting. Then I try to calm them down and assure them that investing is a long game, and over time they’ll do better staying the course we agreed on than jumping around with every market swing, up or down.”
“Do they listen?”
“Most of them. Eventually.”
4. Speakers’ booking agents
Matching clients with speakers can bring curious challenges. Celebrity speakers in particular may have unique requirements that the agents who book them must figure out and comply with. Or else.
For instance, one young man I met had to book a distinguished jurist. He needed to be picked up in a limo. The limo had to be a Bentley. And the Bentley had to be gray.
Well, excuse me.
5. Waiters
I think the favored term these days is “Servers.” Servers serve strangers. Some strangers are pleasant and courteous. Not all. Waiters mean to please, but to do that they have to put up with a lot. Always with a smile, of course.
Customers ask silly questions. (“What’s good here?”) Some don’t find the menu detailed enough. (“Can I have half of this and some of that, with the sauce on the side?”) They may find the food too hot. Or too cold. Or too spicy. Or too bland. After all that, they may tip a little. Or not.
But the server still has to ask, “Is everything satisfactory?”
6. Psychologists
Never mind.
7. Parking meter readers
Just kidding. Meter readers write parking tickets.
They know perfectly well that everyone knows exactly what they do. And they don’t care.
8. People who field complaints at call centers
Requirement: Patience, savvy, Xanax.
9. Dermatologists
You bet, in spades. I wrote a whole book on the subject. You can read it if you want to. If you disagree, don’t tell me.
I don’t need readers to disagree with me. I already have patients.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com .
The chief complaint
In medical school, they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.
“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure …”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry, too. Very sorry, indeed. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
In medical school, they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.
“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure …”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry, too. Very sorry, indeed. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
In medical school, they taught us to learn the patient’s chief complaint.
In dermatology the presenting complaint is on the outside, where the skin is. The chief complaint is often deeper.
Sandra
“How are your parents?”
“Getting older. I’m over their house every day. It’s always something.
“My husband had a stroke this year. Our daughter – she’s a nurse – made him get help. ‘You’re not talking right,’ she said to him. You’re going to the hospital right now.’
“Stan’s at home. He can’t work construction anymore. When I get back from taking care of my parents, I take care of him.”
Sandra’s moles are normal. Who is taking care of her?
Grigoriy
“I’ve had a hard life,” says Grigoriy, apropos of nothing.
“How?”
“My father was important in the Communist party. Stalin purged him in 1938. I was a teenager. “They kept me in a cell of one room for 15 years.”
“Why did they put you in jail?”
“I was my father’s son.”
Phil
Phil is in for his annual. He looks robust, but thinner.
“Sorry I missed last year,” he says. “I was clearing my throat a lot. An ENT doctor found that I had cancer of the vocal cords. I got 39 radiation sessions. They said I would handle them OK, but afterward, I’d feel awful. They were right.
“I lost 20 pounds,” says Phil. “But now I’m getting back to myself.” His smile is broad, but uncertain.
Fred
Fred’s rash is impressive: big, purple blotches all over. Could be a drug eruption, only he takes no drugs.
“It may be viral,” I say.
“Can I visit my Dad in Providence Sunday?” he asks. “It’s Father’s Day.”
“I’m not sure …”
“Dad has cancer of the esophagus. They’re hoping that chemo may buy him a little time.”
I tell Fred to wash carefully. Some things can’t be rescheduled.
Emily
Emily’s Mom has left me a note to read before I see her daughter. It lists Emily’s five psychoactive medications.
Emily is lying on her back and does not sit up. Her gaze is vague and unfocused.
Emily has moderate papular acne on her cheeks. That is her presenting complaint. It is not her chief complaint. As for what her mother goes through, I can barely imagine.
Brenda
Brenda comes for 6-month skin checks. Usually with her husband Glen, but not today.
“Glen’s not so well,” Brenda says. The doctors diagnosed him with MS. They’re vague about how fast it will progress. I guess they don’t know.
“To tell the truth, Glen’s pretty depressed. But he doesn’t want to talk to anyone about it. Do you know a psychiatrist who specializes in MS patients? Glen might take your advice.”
Tom
“It’s been a tough year. Eddie died. You saw him years ago, I think.”
I actually remember Eddie. A troubled kid with terrible acne. He had one visit, never came back.
“I was walking in a mountain field in Cambodia when I got the word,” says Tom. “My ex called me. ‘Tom died,’ she said. ‘Drug overdose. Come home.’
“Every year I walk through Cambodia and Myanmar for a month,” says Tom. “Just to be alone. The people there are nice. They let me be.
“Eddie was a good boy. He hung with the wrong crowd. He made a mistake, and he could never get past it. I think of him every day.”
Frank
Frank doesn’t pick. Frank gouges. He’s been gouging his forearms for years. Intralesional steroids help a little. But he can’t stop.
“I guess it’s stress,” Frank says.
“How about avoiding stress?” I ask, with a smile.
Frank breaks down and weeps.
“I’m sorry,” he says. He gathers himself. “My wife has breast cancer. Mammogram showed a spot 4 years ago. Then it grew. It’s already stage four. Our kids are teenagers.”
Frank breaks down again. He apologizes again. “I’m so sorry for being like this.” Again he weeps, again he apologizes. “I shouldn’t act like this,” he says. “I’m sorry.”
I am sorry, too. Very sorry, indeed. But for patients’ true chief complaints, often incidental to the superficial presenting ones, all I can do is listen. It’s not much, but it’s the best I can do. For many patients, over many years, listening has been the most I’ve had to offer.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Damned documentation
Sorry, but I can’t help you. What I can do is tell you you’re not alone. Datamania is now an endemic malady. Everybody has it and everybody’s doing it, even some you’d never imagine. If misery loves company, you should soon be head over heels.
1. Tiers for Tots
“What are the parents like?” I ask.
“They’re great!” Tracy says. “They want their kids to be creative and play.”
She frowns. “But my boss insists I give him data.”
“Data? What data?”
“Studies show that letter recognition in kindergarten correlates with reading ability in third grade,” she says. “So I have to test the kids and provide him with the data.”
“And what if the kids flub letter recognition?”
Tracy’s smile is now rueful. “Then they might need a Tier 2 intervention.”
“Good grief! What is a Tier 2 intervention?”
“It’s time consuming,” she says. “It takes a lot of one-on-one work, me and the kid.”
Less play all around, I guess. But documentation must be done, and data delivered. By the kindergarten teacher!
2. Filing for firefighters
Bruce has been a firefighter for 30 years, and it’s starting to wear him down. The physical exertion? The stress? Nah.
“The paperwork is driving me crazy,” he says.
“What paperwork?”
“In between calls, we spend hours filling out forms,” he says.
“Which forms?”
“At the scene, you go to work on the fire and help people get to safety. Then you see how they’re doing, and refer the ones who need it for medical help.
“Used to be,” says Bruce, “that you’d eyeball someone, ask them how they felt and if they needed to go to the hospital. If they said they were OK, they were good to leave.”
“And now?”
“Now we have to cover ourselves. We need to document how they look, what they say, what we asked them, what they answered. They have to sign a release that we asked them what we needed to ask and they answered what we needed to hear, that they said they were OK and didn’t need to go to the ER and signed off on it. Takes a lot of time.”
And paper. Maybe little kids who used to dream of being firefighters will start to dream that they’ll be file clerks with big red hats.
3. Your personal banker doesn’t know you!
Marina looks frazzled. “Stress at work,” she says. “It gets worse all the time.”
I know Marina works at a community bank. “What’s the problem?” I ask. “More restrictions on lending?”
“Oh sure,” she says, “but that’s an old story. Now there are new regulations to prevent money laundering. We have to know the identity of anybody who makes a deposit.”
“Sounds reasonable.”
“In principle sure,” she says. “But in practice what happens is this: Somebody wants to make any change – to add a relative, upgrade to a newer checking account. Even if they’ve been our depositors for 20 years, we have to ask them to produce all kinds of personal information for us to show regulators if they ask if we know people we’ve known forever.”
“Do the regulators ever ask?”
“Of course not,” says Marina. “But we have to fill out the forms, which take all day.”
It’s everywhere, folks. Bureaucratization is pervasive. No one can escape. Where is Franz Kafka now that we need him?
We in medicine know this all too well, of course. Perhaps the leading cause of physician retirement is introducing EHR into the institutions they work at.
There are, of course, always reasons and justifications for bureaucratic rules. You know them all, and it doesn’t matter. Fish gotta swim and clerks gotta file. Besides, it is now an article of faith that from large data sets shall go forth great wisdom. In precision medicine. Also, in kindergarten.
Sorry, but I have to go. I’m doing my charts, and there are templates to paste and boilers to plate.
As the apocryphal cardiologist may have said, “Hey, things could be worse. I could be younger.”
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Sorry, but I can’t help you. What I can do is tell you you’re not alone. Datamania is now an endemic malady. Everybody has it and everybody’s doing it, even some you’d never imagine. If misery loves company, you should soon be head over heels.
1. Tiers for Tots
“What are the parents like?” I ask.
“They’re great!” Tracy says. “They want their kids to be creative and play.”
She frowns. “But my boss insists I give him data.”
“Data? What data?”
“Studies show that letter recognition in kindergarten correlates with reading ability in third grade,” she says. “So I have to test the kids and provide him with the data.”
“And what if the kids flub letter recognition?”
Tracy’s smile is now rueful. “Then they might need a Tier 2 intervention.”
“Good grief! What is a Tier 2 intervention?”
“It’s time consuming,” she says. “It takes a lot of one-on-one work, me and the kid.”
Less play all around, I guess. But documentation must be done, and data delivered. By the kindergarten teacher!
2. Filing for firefighters
Bruce has been a firefighter for 30 years, and it’s starting to wear him down. The physical exertion? The stress? Nah.
“The paperwork is driving me crazy,” he says.
“What paperwork?”
“In between calls, we spend hours filling out forms,” he says.
“Which forms?”
“At the scene, you go to work on the fire and help people get to safety. Then you see how they’re doing, and refer the ones who need it for medical help.
“Used to be,” says Bruce, “that you’d eyeball someone, ask them how they felt and if they needed to go to the hospital. If they said they were OK, they were good to leave.”
“And now?”
“Now we have to cover ourselves. We need to document how they look, what they say, what we asked them, what they answered. They have to sign a release that we asked them what we needed to ask and they answered what we needed to hear, that they said they were OK and didn’t need to go to the ER and signed off on it. Takes a lot of time.”
And paper. Maybe little kids who used to dream of being firefighters will start to dream that they’ll be file clerks with big red hats.
3. Your personal banker doesn’t know you!
Marina looks frazzled. “Stress at work,” she says. “It gets worse all the time.”
I know Marina works at a community bank. “What’s the problem?” I ask. “More restrictions on lending?”
“Oh sure,” she says, “but that’s an old story. Now there are new regulations to prevent money laundering. We have to know the identity of anybody who makes a deposit.”
“Sounds reasonable.”
“In principle sure,” she says. “But in practice what happens is this: Somebody wants to make any change – to add a relative, upgrade to a newer checking account. Even if they’ve been our depositors for 20 years, we have to ask them to produce all kinds of personal information for us to show regulators if they ask if we know people we’ve known forever.”
“Do the regulators ever ask?”
“Of course not,” says Marina. “But we have to fill out the forms, which take all day.”
It’s everywhere, folks. Bureaucratization is pervasive. No one can escape. Where is Franz Kafka now that we need him?
We in medicine know this all too well, of course. Perhaps the leading cause of physician retirement is introducing EHR into the institutions they work at.
There are, of course, always reasons and justifications for bureaucratic rules. You know them all, and it doesn’t matter. Fish gotta swim and clerks gotta file. Besides, it is now an article of faith that from large data sets shall go forth great wisdom. In precision medicine. Also, in kindergarten.
Sorry, but I have to go. I’m doing my charts, and there are templates to paste and boilers to plate.
As the apocryphal cardiologist may have said, “Hey, things could be worse. I could be younger.”
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Sorry, but I can’t help you. What I can do is tell you you’re not alone. Datamania is now an endemic malady. Everybody has it and everybody’s doing it, even some you’d never imagine. If misery loves company, you should soon be head over heels.
1. Tiers for Tots
“What are the parents like?” I ask.
“They’re great!” Tracy says. “They want their kids to be creative and play.”
She frowns. “But my boss insists I give him data.”
“Data? What data?”
“Studies show that letter recognition in kindergarten correlates with reading ability in third grade,” she says. “So I have to test the kids and provide him with the data.”
“And what if the kids flub letter recognition?”
Tracy’s smile is now rueful. “Then they might need a Tier 2 intervention.”
“Good grief! What is a Tier 2 intervention?”
“It’s time consuming,” she says. “It takes a lot of one-on-one work, me and the kid.”
Less play all around, I guess. But documentation must be done, and data delivered. By the kindergarten teacher!
2. Filing for firefighters
Bruce has been a firefighter for 30 years, and it’s starting to wear him down. The physical exertion? The stress? Nah.
“The paperwork is driving me crazy,” he says.
“What paperwork?”
“In between calls, we spend hours filling out forms,” he says.
“Which forms?”
“At the scene, you go to work on the fire and help people get to safety. Then you see how they’re doing, and refer the ones who need it for medical help.
“Used to be,” says Bruce, “that you’d eyeball someone, ask them how they felt and if they needed to go to the hospital. If they said they were OK, they were good to leave.”
“And now?”
“Now we have to cover ourselves. We need to document how they look, what they say, what we asked them, what they answered. They have to sign a release that we asked them what we needed to ask and they answered what we needed to hear, that they said they were OK and didn’t need to go to the ER and signed off on it. Takes a lot of time.”
And paper. Maybe little kids who used to dream of being firefighters will start to dream that they’ll be file clerks with big red hats.
3. Your personal banker doesn’t know you!
Marina looks frazzled. “Stress at work,” she says. “It gets worse all the time.”
I know Marina works at a community bank. “What’s the problem?” I ask. “More restrictions on lending?”
“Oh sure,” she says, “but that’s an old story. Now there are new regulations to prevent money laundering. We have to know the identity of anybody who makes a deposit.”
“Sounds reasonable.”
“In principle sure,” she says. “But in practice what happens is this: Somebody wants to make any change – to add a relative, upgrade to a newer checking account. Even if they’ve been our depositors for 20 years, we have to ask them to produce all kinds of personal information for us to show regulators if they ask if we know people we’ve known forever.”
“Do the regulators ever ask?”
“Of course not,” says Marina. “But we have to fill out the forms, which take all day.”
It’s everywhere, folks. Bureaucratization is pervasive. No one can escape. Where is Franz Kafka now that we need him?
We in medicine know this all too well, of course. Perhaps the leading cause of physician retirement is introducing EHR into the institutions they work at.
There are, of course, always reasons and justifications for bureaucratic rules. You know them all, and it doesn’t matter. Fish gotta swim and clerks gotta file. Besides, it is now an article of faith that from large data sets shall go forth great wisdom. In precision medicine. Also, in kindergarten.
Sorry, but I have to go. I’m doing my charts, and there are templates to paste and boilers to plate.
As the apocryphal cardiologist may have said, “Hey, things could be worse. I could be younger.”
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Fake medical news: The black salve and the black arts
Jake clearly needed a biopsy.
When I suggested that we find out what that new growth on his cheek was, he responded with fear. “Do you really need to test it?” he asked. Then he proposed an alternative.
“I had another spot last year,” he said. “This European doctor I saw in somebody’s home put a special black salve on it, and it went away.”
“Who was this doctor?” I asked.
“At the time, I was a raw vegan,” he said. “One of our group members gave me the doctor’s name. He has a big reputation in Europe. He treated people locally in people’s living rooms.”
“Do you recall his name?” I asked him.
Jake didn’t. But I did.
Three years ago, a frightened, middle-aged woman named Josie came to see me with ugly scarring all over her face.
Josie’s story was similar to Jake’s: A famous European doctor. Somebody’s living room.
“He had me lie on the floor,” she recalled, “and he put on some kind of salve. It burned horribly. I was screaming in pain. He washed it off, but it still burned for a long time. This is what it left,” she said, pointing to denting and discoloration on her cheeks and upper lip. She remembered the man’s name.
It took just a few clicks to find him. He wasn’t a licensed doctor and had fled his home country ahead of fraud charges for illegal and harmful practice.
I couldn’t offer Josie much, beyond advising her to avoid getting treated on living room floors by strange practitioners with painful salves.
If you don’t know about the treatment Josie and Jake underwent – it’s called “escharotic treatment” – you can look it up on Wikipedia. It’s also the topic of a case study in the May issue of JAMA Dermatology (2018;154[5]:618-9).
Escharotic treatment has been around a long time. It is used for cancers of the skin and cervix, among others. The principle behind The idea behind both is to apply something that blisters the skin and raises a scab. The eschar is supposed to draw the evil out of the body and bring cure.
Smile if you want, but this idea has been around forever and will likely outlast many treatments we now use. Fake news is old news, and does not need social media to spread (though Facebook helps).
Apparently ordinary people believe strange, irrational, harmful things. Why? Why on earth would Jake and Josie let somebody they don’t know put black goop that hurts like hell on their faces as they lie on a stranger’s carpet? Some thoughts:
- Fear. They think they have cancer and are afraid to find out.
- Suspicion. They don’t trust doctors.
- People they hang with tell them to. Some groups harbor a suspicious, even hostile stance toward conventional medicine, convinced that its principles are unnatural and its practitioners are more concerned with profit and prestige than with the good of their patients.
Those who hold such beliefs, like various conspiracy theorists, span the political and social spectrum, from left to right, and they’ve been around forever.
I don’t plan to try convincing them otherwise. No one can convince them. Citing facts and authority gets you nowhere. As Jonathan Swift said, “You cannot reason someone out of something they did not reason themselves into.”
Fake political news is a problem for society. Fake medical news can be a problem for doctors. A pediatrician confronting an antivaxer family must decide whether to try negotiating (giving their kid vaccines a little at a time) or to give up and send them elsewhere.
It takes effort for physicians to have patience with people who let unscrupulous strangers etch and mutilate their faces. As professionals, however, we doctors are obligated to care even for people we don’t like or agree with. We should therefore try to understand why people who undertake dangerous and irrational treatments think the way they do.
Often, what such patients mainly are is afraid. Still, the ones who actually show up in our offices are willing to at least consider medical opinion. Those who aren’t would never show up.
Jake had enough faith in me to let me calm him down enough to do the biopsy.
It was benign.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Jake clearly needed a biopsy.
When I suggested that we find out what that new growth on his cheek was, he responded with fear. “Do you really need to test it?” he asked. Then he proposed an alternative.
“I had another spot last year,” he said. “This European doctor I saw in somebody’s home put a special black salve on it, and it went away.”
“Who was this doctor?” I asked.
“At the time, I was a raw vegan,” he said. “One of our group members gave me the doctor’s name. He has a big reputation in Europe. He treated people locally in people’s living rooms.”
“Do you recall his name?” I asked him.
Jake didn’t. But I did.
Three years ago, a frightened, middle-aged woman named Josie came to see me with ugly scarring all over her face.
Josie’s story was similar to Jake’s: A famous European doctor. Somebody’s living room.
“He had me lie on the floor,” she recalled, “and he put on some kind of salve. It burned horribly. I was screaming in pain. He washed it off, but it still burned for a long time. This is what it left,” she said, pointing to denting and discoloration on her cheeks and upper lip. She remembered the man’s name.
It took just a few clicks to find him. He wasn’t a licensed doctor and had fled his home country ahead of fraud charges for illegal and harmful practice.
I couldn’t offer Josie much, beyond advising her to avoid getting treated on living room floors by strange practitioners with painful salves.
If you don’t know about the treatment Josie and Jake underwent – it’s called “escharotic treatment” – you can look it up on Wikipedia. It’s also the topic of a case study in the May issue of JAMA Dermatology (2018;154[5]:618-9).
Escharotic treatment has been around a long time. It is used for cancers of the skin and cervix, among others. The principle behind The idea behind both is to apply something that blisters the skin and raises a scab. The eschar is supposed to draw the evil out of the body and bring cure.
Smile if you want, but this idea has been around forever and will likely outlast many treatments we now use. Fake news is old news, and does not need social media to spread (though Facebook helps).
Apparently ordinary people believe strange, irrational, harmful things. Why? Why on earth would Jake and Josie let somebody they don’t know put black goop that hurts like hell on their faces as they lie on a stranger’s carpet? Some thoughts:
- Fear. They think they have cancer and are afraid to find out.
- Suspicion. They don’t trust doctors.
- People they hang with tell them to. Some groups harbor a suspicious, even hostile stance toward conventional medicine, convinced that its principles are unnatural and its practitioners are more concerned with profit and prestige than with the good of their patients.
Those who hold such beliefs, like various conspiracy theorists, span the political and social spectrum, from left to right, and they’ve been around forever.
I don’t plan to try convincing them otherwise. No one can convince them. Citing facts and authority gets you nowhere. As Jonathan Swift said, “You cannot reason someone out of something they did not reason themselves into.”
Fake political news is a problem for society. Fake medical news can be a problem for doctors. A pediatrician confronting an antivaxer family must decide whether to try negotiating (giving their kid vaccines a little at a time) or to give up and send them elsewhere.
It takes effort for physicians to have patience with people who let unscrupulous strangers etch and mutilate their faces. As professionals, however, we doctors are obligated to care even for people we don’t like or agree with. We should therefore try to understand why people who undertake dangerous and irrational treatments think the way they do.
Often, what such patients mainly are is afraid. Still, the ones who actually show up in our offices are willing to at least consider medical opinion. Those who aren’t would never show up.
Jake had enough faith in me to let me calm him down enough to do the biopsy.
It was benign.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Jake clearly needed a biopsy.
When I suggested that we find out what that new growth on his cheek was, he responded with fear. “Do you really need to test it?” he asked. Then he proposed an alternative.
“I had another spot last year,” he said. “This European doctor I saw in somebody’s home put a special black salve on it, and it went away.”
“Who was this doctor?” I asked.
“At the time, I was a raw vegan,” he said. “One of our group members gave me the doctor’s name. He has a big reputation in Europe. He treated people locally in people’s living rooms.”
“Do you recall his name?” I asked him.
Jake didn’t. But I did.
Three years ago, a frightened, middle-aged woman named Josie came to see me with ugly scarring all over her face.
Josie’s story was similar to Jake’s: A famous European doctor. Somebody’s living room.
“He had me lie on the floor,” she recalled, “and he put on some kind of salve. It burned horribly. I was screaming in pain. He washed it off, but it still burned for a long time. This is what it left,” she said, pointing to denting and discoloration on her cheeks and upper lip. She remembered the man’s name.
It took just a few clicks to find him. He wasn’t a licensed doctor and had fled his home country ahead of fraud charges for illegal and harmful practice.
I couldn’t offer Josie much, beyond advising her to avoid getting treated on living room floors by strange practitioners with painful salves.
If you don’t know about the treatment Josie and Jake underwent – it’s called “escharotic treatment” – you can look it up on Wikipedia. It’s also the topic of a case study in the May issue of JAMA Dermatology (2018;154[5]:618-9).
Escharotic treatment has been around a long time. It is used for cancers of the skin and cervix, among others. The principle behind The idea behind both is to apply something that blisters the skin and raises a scab. The eschar is supposed to draw the evil out of the body and bring cure.
Smile if you want, but this idea has been around forever and will likely outlast many treatments we now use. Fake news is old news, and does not need social media to spread (though Facebook helps).
Apparently ordinary people believe strange, irrational, harmful things. Why? Why on earth would Jake and Josie let somebody they don’t know put black goop that hurts like hell on their faces as they lie on a stranger’s carpet? Some thoughts:
- Fear. They think they have cancer and are afraid to find out.
- Suspicion. They don’t trust doctors.
- People they hang with tell them to. Some groups harbor a suspicious, even hostile stance toward conventional medicine, convinced that its principles are unnatural and its practitioners are more concerned with profit and prestige than with the good of their patients.
Those who hold such beliefs, like various conspiracy theorists, span the political and social spectrum, from left to right, and they’ve been around forever.
I don’t plan to try convincing them otherwise. No one can convince them. Citing facts and authority gets you nowhere. As Jonathan Swift said, “You cannot reason someone out of something they did not reason themselves into.”
Fake political news is a problem for society. Fake medical news can be a problem for doctors. A pediatrician confronting an antivaxer family must decide whether to try negotiating (giving their kid vaccines a little at a time) or to give up and send them elsewhere.
It takes effort for physicians to have patience with people who let unscrupulous strangers etch and mutilate their faces. As professionals, however, we doctors are obligated to care even for people we don’t like or agree with. We should therefore try to understand why people who undertake dangerous and irrational treatments think the way they do.
Often, what such patients mainly are is afraid. Still, the ones who actually show up in our offices are willing to at least consider medical opinion. Those who aren’t would never show up.
Jake had enough faith in me to let me calm him down enough to do the biopsy.
It was benign.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Absurdity
Absurdity is everywhere you look. Or don’t look.
As the old comedian Henny Youngman might have said:
Take my prior authorizations. Please!
Prior authorizations
1. Marissa had been taking isotretinoin for 2 months. She learned that three 20-mg capsules would cost her less than the two 30-mg capsules she’d been on.
My secretary called them. The insurance representative (Pharmacist? Clerk? Gal who stopped by to read the gas meter?) couldn’t help. “When I input your information, it issues a denial.” (Who is “it”? Watson’s evil twin Jensen?)
I got on the phone.
“Forgive me,” I said, gently, “but Marissa has been taking isotretinoin for 2 months, 60-mg per day. She was taking two 30’s. I want her to have three 20’s. They both add up to 60 mg. It’s the same dose. Why do you need to authorize it again?”
“Let me input that,” she replied. “Oh, now it’s accepting it. Your patient can have up to four pills a day.”
I was going to say she only needs three, but kept my mouth shut. Maybe Jensen only authorizes even numbers. 2. Danny has the worst atopic dermatitis I’ve ever seen. It’s all over him and never lets up. Topical steroids don’t touch it. Even prednisone – he’s had plenty over the years – barely makes a dent. I put in a Prior Authorization request for dupilumab.
“Your request for dupilumab has been denied,” read the insurer’s reply. “You have not shown failure with tacrolimus ointment or crisaborole.”
Say what? Prednisone didn’t help, and they expect tacrolimus or crisaborole to do the job?
I prescribed tacrolimus (which doesn’t come in a big enough tube to cover Daniel’s affected area anyway). It failed. Amazing.
“Your request for dupilumab has been denied,” said the insurer. “You have not also shown failure with crisaborole.”
Really? OK, I prescribed crisaborole. They denied coverage for it.
Now I was really getting into this. I wrote them. “I prescribed crisaborole.” I observed, “because you asked me to.”
They approved crisaborole. It failed. I reapplied for dupilumab. No response.
I called the insurer’s medical director, on a mobile with a Missouri exchange. After some telephone tag, he called back. “I cannot discuss this case with you,” he said, “because I have already made my determination.” Then he hung up without telling me what his determination was.
Further phone calls went unanswered. I thought Missouri was the Show-Me state.
The patient remained miserable. I decided to try one last time and wrote a long, sarcastic letter, detailing the whole episode. My secretary sent it off.
They approved dupilumab within the hour.
Malice? Nah, that’s giving them too much credit.
Now all Daniel has to do is improve.
Patient privacy!
Some news from abroad: what we know as HIPAA is called the “Data Protection Act” in the United Kingdom.
“We are obliged to conform to the demands of the Data Protection Act, and this specifically applies to the rabbi publicly mentioning the names of individuals who are unwell. The rabbi can only mention specific individuals with their permission or that of a relative designated by the sick person to do so. Anyone wishing for the rabbi to say a public prayer on their behalf must contact him directly by phone, text, or e-mail. To do anything else is breaking the law.”
If someone breaks this law, perhaps the rabbi can assist with atonement.
In any event, henceforth all entreaties to the Almighty must be encrypted. At least in the U.K.
What???!!!
Marina showed me her sunscreen. The label read, “Protects against UVA and UVB rays.”
“What’s the problem?” I asked.
She showed me our American Academy of Dermatology-produced sunscreen handout, which recommends “a broad-spectrum sunscreen that protects against both UVA and UVB rays, both of which cause cancer.”
“Does this mean my sunscreen causes cancer?” asked Marina.
“Not to worry,” I assured her.
I sighed and wafted a small prayer heavenward. Encrypted, of course.
Lo, the answer from above may tarry, but He will never forget His password.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Absurdity is everywhere you look. Or don’t look.
As the old comedian Henny Youngman might have said:
Take my prior authorizations. Please!
Prior authorizations
1. Marissa had been taking isotretinoin for 2 months. She learned that three 20-mg capsules would cost her less than the two 30-mg capsules she’d been on.
My secretary called them. The insurance representative (Pharmacist? Clerk? Gal who stopped by to read the gas meter?) couldn’t help. “When I input your information, it issues a denial.” (Who is “it”? Watson’s evil twin Jensen?)
I got on the phone.
“Forgive me,” I said, gently, “but Marissa has been taking isotretinoin for 2 months, 60-mg per day. She was taking two 30’s. I want her to have three 20’s. They both add up to 60 mg. It’s the same dose. Why do you need to authorize it again?”
“Let me input that,” she replied. “Oh, now it’s accepting it. Your patient can have up to four pills a day.”
I was going to say she only needs three, but kept my mouth shut. Maybe Jensen only authorizes even numbers. 2. Danny has the worst atopic dermatitis I’ve ever seen. It’s all over him and never lets up. Topical steroids don’t touch it. Even prednisone – he’s had plenty over the years – barely makes a dent. I put in a Prior Authorization request for dupilumab.
“Your request for dupilumab has been denied,” read the insurer’s reply. “You have not shown failure with tacrolimus ointment or crisaborole.”
Say what? Prednisone didn’t help, and they expect tacrolimus or crisaborole to do the job?
I prescribed tacrolimus (which doesn’t come in a big enough tube to cover Daniel’s affected area anyway). It failed. Amazing.
“Your request for dupilumab has been denied,” said the insurer. “You have not also shown failure with crisaborole.”
Really? OK, I prescribed crisaborole. They denied coverage for it.
Now I was really getting into this. I wrote them. “I prescribed crisaborole.” I observed, “because you asked me to.”
They approved crisaborole. It failed. I reapplied for dupilumab. No response.
I called the insurer’s medical director, on a mobile with a Missouri exchange. After some telephone tag, he called back. “I cannot discuss this case with you,” he said, “because I have already made my determination.” Then he hung up without telling me what his determination was.
Further phone calls went unanswered. I thought Missouri was the Show-Me state.
The patient remained miserable. I decided to try one last time and wrote a long, sarcastic letter, detailing the whole episode. My secretary sent it off.
They approved dupilumab within the hour.
Malice? Nah, that’s giving them too much credit.
Now all Daniel has to do is improve.
Patient privacy!
Some news from abroad: what we know as HIPAA is called the “Data Protection Act” in the United Kingdom.
“We are obliged to conform to the demands of the Data Protection Act, and this specifically applies to the rabbi publicly mentioning the names of individuals who are unwell. The rabbi can only mention specific individuals with their permission or that of a relative designated by the sick person to do so. Anyone wishing for the rabbi to say a public prayer on their behalf must contact him directly by phone, text, or e-mail. To do anything else is breaking the law.”
If someone breaks this law, perhaps the rabbi can assist with atonement.
In any event, henceforth all entreaties to the Almighty must be encrypted. At least in the U.K.
What???!!!
Marina showed me her sunscreen. The label read, “Protects against UVA and UVB rays.”
“What’s the problem?” I asked.
She showed me our American Academy of Dermatology-produced sunscreen handout, which recommends “a broad-spectrum sunscreen that protects against both UVA and UVB rays, both of which cause cancer.”
“Does this mean my sunscreen causes cancer?” asked Marina.
“Not to worry,” I assured her.
I sighed and wafted a small prayer heavenward. Encrypted, of course.
Lo, the answer from above may tarry, but He will never forget His password.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.
Absurdity is everywhere you look. Or don’t look.
As the old comedian Henny Youngman might have said:
Take my prior authorizations. Please!
Prior authorizations
1. Marissa had been taking isotretinoin for 2 months. She learned that three 20-mg capsules would cost her less than the two 30-mg capsules she’d been on.
My secretary called them. The insurance representative (Pharmacist? Clerk? Gal who stopped by to read the gas meter?) couldn’t help. “When I input your information, it issues a denial.” (Who is “it”? Watson’s evil twin Jensen?)
I got on the phone.
“Forgive me,” I said, gently, “but Marissa has been taking isotretinoin for 2 months, 60-mg per day. She was taking two 30’s. I want her to have three 20’s. They both add up to 60 mg. It’s the same dose. Why do you need to authorize it again?”
“Let me input that,” she replied. “Oh, now it’s accepting it. Your patient can have up to four pills a day.”
I was going to say she only needs three, but kept my mouth shut. Maybe Jensen only authorizes even numbers. 2. Danny has the worst atopic dermatitis I’ve ever seen. It’s all over him and never lets up. Topical steroids don’t touch it. Even prednisone – he’s had plenty over the years – barely makes a dent. I put in a Prior Authorization request for dupilumab.
“Your request for dupilumab has been denied,” read the insurer’s reply. “You have not shown failure with tacrolimus ointment or crisaborole.”
Say what? Prednisone didn’t help, and they expect tacrolimus or crisaborole to do the job?
I prescribed tacrolimus (which doesn’t come in a big enough tube to cover Daniel’s affected area anyway). It failed. Amazing.
“Your request for dupilumab has been denied,” said the insurer. “You have not also shown failure with crisaborole.”
Really? OK, I prescribed crisaborole. They denied coverage for it.
Now I was really getting into this. I wrote them. “I prescribed crisaborole.” I observed, “because you asked me to.”
They approved crisaborole. It failed. I reapplied for dupilumab. No response.
I called the insurer’s medical director, on a mobile with a Missouri exchange. After some telephone tag, he called back. “I cannot discuss this case with you,” he said, “because I have already made my determination.” Then he hung up without telling me what his determination was.
Further phone calls went unanswered. I thought Missouri was the Show-Me state.
The patient remained miserable. I decided to try one last time and wrote a long, sarcastic letter, detailing the whole episode. My secretary sent it off.
They approved dupilumab within the hour.
Malice? Nah, that’s giving them too much credit.
Now all Daniel has to do is improve.
Patient privacy!
Some news from abroad: what we know as HIPAA is called the “Data Protection Act” in the United Kingdom.
“We are obliged to conform to the demands of the Data Protection Act, and this specifically applies to the rabbi publicly mentioning the names of individuals who are unwell. The rabbi can only mention specific individuals with their permission or that of a relative designated by the sick person to do so. Anyone wishing for the rabbi to say a public prayer on their behalf must contact him directly by phone, text, or e-mail. To do anything else is breaking the law.”
If someone breaks this law, perhaps the rabbi can assist with atonement.
In any event, henceforth all entreaties to the Almighty must be encrypted. At least in the U.K.
What???!!!
Marina showed me her sunscreen. The label read, “Protects against UVA and UVB rays.”
“What’s the problem?” I asked.
She showed me our American Academy of Dermatology-produced sunscreen handout, which recommends “a broad-spectrum sunscreen that protects against both UVA and UVB rays, both of which cause cancer.”
“Does this mean my sunscreen causes cancer?” asked Marina.
“Not to worry,” I assured her.
I sighed and wafted a small prayer heavenward. Encrypted, of course.
Lo, the answer from above may tarry, but He will never forget His password.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@mdedge.com.