Under My Skin

Good evening. How many of you have heard the expression, "The doctor hung out his shingle?"

Nobody? Well, no surprise.

It's a pleasure to speak to a group like this, high-school students from around the country interested in medicine. And you have the opportunity to meet speakers from all realms of the medical profession. My job tonight, as a practitioner here in town, is to tell you my story. I hope you find hearing it useful, but your stories, however they may develop, will be different than mine.

Hanging out a shingle once meant opening a medical practice. Picture a doctor setting up a solo practice in their home and telling the world they have arrived by hanging a shingle with their name on it from a post in their lawn. You've probably never heard this expression before because nobody goes into solo practice anymore, certainly not in their house.

Times do change in unpredictable ways. In 1981, I took over the practice of a retiring dermatologist. As we met in his home office, a converted garage, he sat across his desk and said, "You young people like to spend money on unnecessary things, like secretaries." I smiled to myself and looked at him the way you are looking at me, which is how the next generation will someday look at you.

If you had told me 30 years ago that a doctor would need not just a telephone but a whole telecommunications system with voicemail, a network of computers, and an army of clerks to enter data, check insurance eligibility online, scan insurance cards and privacy disclaimers, and access electronic medical records, I would have thought you had landed from another planet.

Voicemail, computers, e-mail, online, not to mention PPOs, OSHA and HIPAA regulations, ICD-9 codes, and concierge practices – in which you pay a doctor extra for the honor of having your phone calls returned – nobody could have foreseen any of these novelties, and no one can predict what developments there will be 30 years from now. The only sure thing is that changes will happen, and in whatever profession you enter you will deal with them because you have to.

But there is one constant. Although technology advances and systems change, people don’t.

Six years ago, I spoke to students at this forum and told them how I became a dermatologist. In college, I majored in math, lost interest, didn’t know what else to do, and followed a friend’s advice that medicine might be a good choice. In medical school, I chose pediatrics because the internists at my alma mater were intimidating, and the pediatricians were nice.

Out of residency, I took a job at a university-connected hospital, where my boss told me I needed "a gimmick" to stay in academics and proposed dermatology, which I had never encountered or thought of in school.

I spent time with a dermatologist and pretended to be one myself until my hospital lost its university affiliation. Since there were no opportunities for pediatric practice in the town I was living, my wife, our three small children, and I moved up this way, where I retrained in dermatology.

Not a very well-considered decision, was it?

The students I was addressing were miffed. They were expecting a more linear, perhaps inspirational, narrative, along the lines of: I always wanted to cure skin disease and help humanity. But that's not how it was, and if you ask your parents and other adults how they got where they are, you will find that’s not generally how it is.

But the punch line is that it turns out I do want to save humanity, at least one patient at a time, I do want to heal the sick and comfort the afflicted. But, at your age and for some time after, I didn’t know it yet. At 17, what can you know about your life? You haven’t lived it. But you will.

With opportunity, family support, hard work, and good luck, I was eventually able to figure out what I wanted to do and to spend the rest of my professional life doing it. May you have similar fortune in the field you pursue.

If you do join the medical profession, you will adapt to changes no one can anticipate. But however diseases evolve and therapies advance, people will continue to worry, to get sick, and to die. They will need your help to navigate their journey. That won’t change, whether you tell the world you’ve arrived by launching a website or by hanging a shingle on your front lawn.

Thank you for listening. I wish all of you success, contentment, and the very best of luck

Good evening. How many of you have heard the expression, "The doctor hung out his shingle?"

Nobody? Well, no surprise.

It's a pleasure to speak to a group like this, high-school students from around the country interested in medicine. And you have the opportunity to meet speakers from all realms of the medical profession. My job tonight, as a practitioner here in town, is to tell you my story. I hope you find hearing it useful, but your stories, however they may develop, will be different than mine.

Hanging out a shingle once meant opening a medical practice. Picture a doctor setting up a solo practice in their home and telling the world they have arrived by hanging a shingle with their name on it from a post in their lawn. You've probably never heard this expression before because nobody goes into solo practice anymore, certainly not in their house.

Times do change in unpredictable ways. In 1981, I took over the practice of a retiring dermatologist. As we met in his home office, a converted garage, he sat across his desk and said, "You young people like to spend money on unnecessary things, like secretaries." I smiled to myself and looked at him the way you are looking at me, which is how the next generation will someday look at you.

If you had told me 30 years ago that a doctor would need not just a telephone but a whole telecommunications system with voicemail, a network of computers, and an army of clerks to enter data, check insurance eligibility online, scan insurance cards and privacy disclaimers, and access electronic medical records, I would have thought you had landed from another planet.

Voicemail, computers, e-mail, online, not to mention PPOs, OSHA and HIPAA regulations, ICD-9 codes, and concierge practices – in which you pay a doctor extra for the honor of having your phone calls returned – nobody could have foreseen any of these novelties, and no one can predict what developments there will be 30 years from now. The only sure thing is that changes will happen, and in whatever profession you enter you will deal with them because you have to.

But there is one constant. Although technology advances and systems change, people don’t.

Six years ago, I spoke to students at this forum and told them how I became a dermatologist. In college, I majored in math, lost interest, didn’t know what else to do, and followed a friend’s advice that medicine might be a good choice. In medical school, I chose pediatrics because the internists at my alma mater were intimidating, and the pediatricians were nice.

Out of residency, I took a job at a university-connected hospital, where my boss told me I needed "a gimmick" to stay in academics and proposed dermatology, which I had never encountered or thought of in school.

I spent time with a dermatologist and pretended to be one myself until my hospital lost its university affiliation. Since there were no opportunities for pediatric practice in the town I was living, my wife, our three small children, and I moved up this way, where I retrained in dermatology.

Not a very well-considered decision, was it?

The students I was addressing were miffed. They were expecting a more linear, perhaps inspirational, narrative, along the lines of: I always wanted to cure skin disease and help humanity. But that's not how it was, and if you ask your parents and other adults how they got where they are, you will find that’s not generally how it is.

But the punch line is that it turns out I do want to save humanity, at least one patient at a time, I do want to heal the sick and comfort the afflicted. But, at your age and for some time after, I didn’t know it yet. At 17, what can you know about your life? You haven’t lived it. But you will.

With opportunity, family support, hard work, and good luck, I was eventually able to figure out what I wanted to do and to spend the rest of my professional life doing it. May you have similar fortune in the field you pursue.

If you do join the medical profession, you will adapt to changes no one can anticipate. But however diseases evolve and therapies advance, people will continue to worry, to get sick, and to die. They will need your help to navigate their journey. That won’t change, whether you tell the world you’ve arrived by launching a website or by hanging a shingle on your front lawn.

Thank you for listening. I wish all of you success, contentment, and the very best of luck

Good evening. How many of you have heard the expression, "The doctor hung out his shingle?"

Nobody? Well, no surprise.

It's a pleasure to speak to a group like this, high-school students from around the country interested in medicine. And you have the opportunity to meet speakers from all realms of the medical profession. My job tonight, as a practitioner here in town, is to tell you my story. I hope you find hearing it useful, but your stories, however they may develop, will be different than mine.

Hanging out a shingle once meant opening a medical practice. Picture a doctor setting up a solo practice in their home and telling the world they have arrived by hanging a shingle with their name on it from a post in their lawn. You've probably never heard this expression before because nobody goes into solo practice anymore, certainly not in their house.

Times do change in unpredictable ways. In 1981, I took over the practice of a retiring dermatologist. As we met in his home office, a converted garage, he sat across his desk and said, "You young people like to spend money on unnecessary things, like secretaries." I smiled to myself and looked at him the way you are looking at me, which is how the next generation will someday look at you.

If you had told me 30 years ago that a doctor would need not just a telephone but a whole telecommunications system with voicemail, a network of computers, and an army of clerks to enter data, check insurance eligibility online, scan insurance cards and privacy disclaimers, and access electronic medical records, I would have thought you had landed from another planet.

Voicemail, computers, e-mail, online, not to mention PPOs, OSHA and HIPAA regulations, ICD-9 codes, and concierge practices – in which you pay a doctor extra for the honor of having your phone calls returned – nobody could have foreseen any of these novelties, and no one can predict what developments there will be 30 years from now. The only sure thing is that changes will happen, and in whatever profession you enter you will deal with them because you have to.

But there is one constant. Although technology advances and systems change, people don’t.

Six years ago, I spoke to students at this forum and told them how I became a dermatologist. In college, I majored in math, lost interest, didn’t know what else to do, and followed a friend’s advice that medicine might be a good choice. In medical school, I chose pediatrics because the internists at my alma mater were intimidating, and the pediatricians were nice.

Out of residency, I took a job at a university-connected hospital, where my boss told me I needed "a gimmick" to stay in academics and proposed dermatology, which I had never encountered or thought of in school.

I spent time with a dermatologist and pretended to be one myself until my hospital lost its university affiliation. Since there were no opportunities for pediatric practice in the town I was living, my wife, our three small children, and I moved up this way, where I retrained in dermatology.

Not a very well-considered decision, was it?

The students I was addressing were miffed. They were expecting a more linear, perhaps inspirational, narrative, along the lines of: I always wanted to cure skin disease and help humanity. But that's not how it was, and if you ask your parents and other adults how they got where they are, you will find that’s not generally how it is.

But the punch line is that it turns out I do want to save humanity, at least one patient at a time, I do want to heal the sick and comfort the afflicted. But, at your age and for some time after, I didn’t know it yet. At 17, what can you know about your life? You haven’t lived it. But you will.

With opportunity, family support, hard work, and good luck, I was eventually able to figure out what I wanted to do and to spend the rest of my professional life doing it. May you have similar fortune in the field you pursue.

If you do join the medical profession, you will adapt to changes no one can anticipate. But however diseases evolve and therapies advance, people will continue to worry, to get sick, and to die. They will need your help to navigate their journey. That won’t change, whether you tell the world you’ve arrived by launching a website or by hanging a shingle on your front lawn.

Thank you for listening. I wish all of you success, contentment, and the very best of luck

I thought I'd seen it all, until Jack took off his shirt. On his chest, back, and arms were a dozen round stickers, each the canary color of smiley faces. What now? Day-Glo nicotine patches?

Jack explained. "The last time you took off my age spots," he said, "you missed a few. So I marked them." Sure enough, next to each sticker a brown excrescence glared like a crusty reproach. No way would I miss those babies this time.

Image courtesy of Wikimedia Commons user Pumbaa80

Now I was back on familiar ground. Over the years, I've seen patients mark spots that concern them with ink dots, ink circles, mascara circles, crude but elaborate anatomical drawings studded with dots (I keep some in my files - they could be worth something some day), and narrative descriptions written in the style of treasure maps, ("Go 3 inches above the left third knuckle, turn right.")
This is not satire. This is life.

Many patients have obsessional tendencies and they show up with lists - of questions, of spots - which they absolutely must get through before life can go on. One or two such patients can be amusing, annoying, challenging, or maddening. Three in a row, and I need a stiff scotch.

When it comes to concerns about spots, the distinction between "medical" and "cosmetic" is irrelevant. It matters not whether the offending spots are skin tags, warts, or actinic keratoses.

People point to and lovingly massage each one in turn, because the spot mars their surface and offends them the same way a piece of tomato hanging off your dining partner's lip may offend you, or a run in your pantyhose, or a scratch on the hood of your shiny new car. The lip, stocking, and the car work just fine, but there's a spot, and you've got to get it off!

Over the years, I've developed strategies to deal with patients with lists of spots or questions.

Get hold of that list! Gently extract the slip of paper, and tick off the items one by one. This helps spare your anxious patient the chore of rereading over and over the ones you already covered, fearful that you missed one.

Wait until the list is done. This may be hard, especially if the list is memorized and you don't know how long it's going to be.

You can tell a lot by body language, however. As you go from point to point, or spot to spot, patients will stay tense and hunched over, with a look of fear and anxiety lest something get skipped. Trying to wrap things up before they're done will make them angry and resentful. Thus distracted, they may forget one, then call or return with a reproachful, "You missed a spot!" Actually, many patients soften their critique by saying, "I think we missed a spot." We're in this together!

Be specific. Don't just look at the back and say, "Everything here looks all right." Instead, point at each spot in particular and comment on it. You must specify that you saw exactly what was worrying the patient (or spouse) and announce that it doesn't worry you.

For especially obsessive people, I advise using this three-part formula: "I am looking at this spot. I can see it. And it's okay." Only when you say all three - in order! -will your patient relax.

Have patients mark their spots at home. Even laid-back people can't find what they're looking for and become anxious and agitated when an impatient, white-coated figure is standing over them with a spray can of liquid nitrogen or an electric needle. That to them is a guarantee you'll miss a spot. (Okay, both of you will miss the spot.)

If patients want you to scour their integument on a search-and-destroy mission, ask them to spend a few minutes the night before in the comfort of their own bedroom marking off what they want done or looked at. That way they can't blame you for sloppiness. Tell them they can use ink, marker, or mascara. Or even yellow stickers.

Editor's Note: This column first appeared in "Skin & Allergy News" in February 1999. This column, along with other "Under My Skin" columns, will be featured in Dr. Rockoff's book, "Under My Skin: A Dermatologist Looks at His Profession and His Patients." It will be available through sites like Amazon.  Dr. Rockoff will donate all author royalties for books bought by dermatologists to Camp Discovery.

I thought I'd seen it all, until Jack took off his shirt. On his chest, back, and arms were a dozen round stickers, each the canary color of smiley faces. What now? Day-Glo nicotine patches?

Jack explained. "The last time you took off my age spots," he said, "you missed a few. So I marked them." Sure enough, next to each sticker a brown excrescence glared like a crusty reproach. No way would I miss those babies this time.

Image courtesy of Wikimedia Commons user Pumbaa80

Now I was back on familiar ground. Over the years, I've seen patients mark spots that concern them with ink dots, ink circles, mascara circles, crude but elaborate anatomical drawings studded with dots (I keep some in my files - they could be worth something some day), and narrative descriptions written in the style of treasure maps, ("Go 3 inches above the left third knuckle, turn right.")
This is not satire. This is life.

Many patients have obsessional tendencies and they show up with lists - of questions, of spots - which they absolutely must get through before life can go on. One or two such patients can be amusing, annoying, challenging, or maddening. Three in a row, and I need a stiff scotch.

When it comes to concerns about spots, the distinction between "medical" and "cosmetic" is irrelevant. It matters not whether the offending spots are skin tags, warts, or actinic keratoses.

People point to and lovingly massage each one in turn, because the spot mars their surface and offends them the same way a piece of tomato hanging off your dining partner's lip may offend you, or a run in your pantyhose, or a scratch on the hood of your shiny new car. The lip, stocking, and the car work just fine, but there's a spot, and you've got to get it off!

Over the years, I've developed strategies to deal with patients with lists of spots or questions.

Get hold of that list! Gently extract the slip of paper, and tick off the items one by one. This helps spare your anxious patient the chore of rereading over and over the ones you already covered, fearful that you missed one.

Wait until the list is done. This may be hard, especially if the list is memorized and you don't know how long it's going to be.

You can tell a lot by body language, however. As you go from point to point, or spot to spot, patients will stay tense and hunched over, with a look of fear and anxiety lest something get skipped. Trying to wrap things up before they're done will make them angry and resentful. Thus distracted, they may forget one, then call or return with a reproachful, "You missed a spot!" Actually, many patients soften their critique by saying, "I think we missed a spot." We're in this together!

Be specific. Don't just look at the back and say, "Everything here looks all right." Instead, point at each spot in particular and comment on it. You must specify that you saw exactly what was worrying the patient (or spouse) and announce that it doesn't worry you.

For especially obsessive people, I advise using this three-part formula: "I am looking at this spot. I can see it. And it's okay." Only when you say all three - in order! -will your patient relax.

Have patients mark their spots at home. Even laid-back people can't find what they're looking for and become anxious and agitated when an impatient, white-coated figure is standing over them with a spray can of liquid nitrogen or an electric needle. That to them is a guarantee you'll miss a spot. (Okay, both of you will miss the spot.)

If patients want you to scour their integument on a search-and-destroy mission, ask them to spend a few minutes the night before in the comfort of their own bedroom marking off what they want done or looked at. That way they can't blame you for sloppiness. Tell them they can use ink, marker, or mascara. Or even yellow stickers.

Editor's Note: This column first appeared in "Skin & Allergy News" in February 1999. This column, along with other "Under My Skin" columns, will be featured in Dr. Rockoff's book, "Under My Skin: A Dermatologist Looks at His Profession and His Patients." It will be available through sites like Amazon.  Dr. Rockoff will donate all author royalties for books bought by dermatologists to Camp Discovery.

I thought I'd seen it all, until Jack took off his shirt. On his chest, back, and arms were a dozen round stickers, each the canary color of smiley faces. What now? Day-Glo nicotine patches?

Jack explained. "The last time you took off my age spots," he said, "you missed a few. So I marked them." Sure enough, next to each sticker a brown excrescence glared like a crusty reproach. No way would I miss those babies this time.

Image courtesy of Wikimedia Commons user Pumbaa80

Now I was back on familiar ground. Over the years, I've seen patients mark spots that concern them with ink dots, ink circles, mascara circles, crude but elaborate anatomical drawings studded with dots (I keep some in my files - they could be worth something some day), and narrative descriptions written in the style of treasure maps, ("Go 3 inches above the left third knuckle, turn right.")
This is not satire. This is life.

Many patients have obsessional tendencies and they show up with lists - of questions, of spots - which they absolutely must get through before life can go on. One or two such patients can be amusing, annoying, challenging, or maddening. Three in a row, and I need a stiff scotch.

When it comes to concerns about spots, the distinction between "medical" and "cosmetic" is irrelevant. It matters not whether the offending spots are skin tags, warts, or actinic keratoses.

People point to and lovingly massage each one in turn, because the spot mars their surface and offends them the same way a piece of tomato hanging off your dining partner's lip may offend you, or a run in your pantyhose, or a scratch on the hood of your shiny new car. The lip, stocking, and the car work just fine, but there's a spot, and you've got to get it off!

Over the years, I've developed strategies to deal with patients with lists of spots or questions.

Get hold of that list! Gently extract the slip of paper, and tick off the items one by one. This helps spare your anxious patient the chore of rereading over and over the ones you already covered, fearful that you missed one.

Wait until the list is done. This may be hard, especially if the list is memorized and you don't know how long it's going to be.

You can tell a lot by body language, however. As you go from point to point, or spot to spot, patients will stay tense and hunched over, with a look of fear and anxiety lest something get skipped. Trying to wrap things up before they're done will make them angry and resentful. Thus distracted, they may forget one, then call or return with a reproachful, "You missed a spot!" Actually, many patients soften their critique by saying, "I think we missed a spot." We're in this together!

Be specific. Don't just look at the back and say, "Everything here looks all right." Instead, point at each spot in particular and comment on it. You must specify that you saw exactly what was worrying the patient (or spouse) and announce that it doesn't worry you.

For especially obsessive people, I advise using this three-part formula: "I am looking at this spot. I can see it. And it's okay." Only when you say all three - in order! -will your patient relax.

Have patients mark their spots at home. Even laid-back people can't find what they're looking for and become anxious and agitated when an impatient, white-coated figure is standing over them with a spray can of liquid nitrogen or an electric needle. That to them is a guarantee you'll miss a spot. (Okay, both of you will miss the spot.)

If patients want you to scour their integument on a search-and-destroy mission, ask them to spend a few minutes the night before in the comfort of their own bedroom marking off what they want done or looked at. That way they can't blame you for sloppiness. Tell them they can use ink, marker, or mascara. Or even yellow stickers.

Editor's Note: This column first appeared in "Skin & Allergy News" in February 1999. This column, along with other "Under My Skin" columns, will be featured in Dr. Rockoff's book, "Under My Skin: A Dermatologist Looks at His Profession and His Patients." It will be available through sites like Amazon.  Dr. Rockoff will donate all author royalties for books bought by dermatologists to Camp Discovery.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these performance measures to rank doctors: the higher the tier, the lower the copay for patients.

Not too long ago, I crowed about being Tier 1. They say pride goes before a fall. Sometimes it goes before the spring.

An insurer who rated me Tier 1 for 2010 sent this year’s ratings. Tier 2. Demoted.

The shame!

But then I saw hope – I could appeal! I e-mailed a request for the data on which my designation was based. Promptly it came: a spreadsheet with 49 columns, plus A through Z, plus AA ... you get the picture. Reading down, there were 4,253 rows listing patients’ financial and demographic details. Across were headings like, "ACT_WT_PAID_TOT_AMT," explained elsewhere as, "Weighted actual payments for this ETG at peer rates."

Scanning screens of unfamiliar acronyms and tiny numbers (the spreadsheet was far too unwieldy to print out), I prepared my appeal. It had three main points:

– Only 47% of the patients showed names and dates of birth; the demographics for the rest were blank, making it impossible to check the data’s relevance and accuracy.

– Some categories made little or no sense. For instance, one ETG (see below) on which I had supposedly done well relative to peers was, "Malignant neoplasm of the skin, major, w/o surgery." What could major skin cancer without surgery possibly mean? An ETG on which I had done poorly was, "Malignant neoplasms of the skin, major, with surgery" – but 1,655 patients were classed as "Neoplasm of." Were these benign Neoplasms of? Malignant Neoplasms of? Major? Minor? W/ surgery? W/o? Who could know?

– One named patient I recognized was listed under the ETG "Infection." Line K, "weighted, actual payments," for this patient were $1,850.04 for 2009 (the "midpoint year.") I had seen this patient three times for oral herpes simplex in 2009, twice in 2008 for seborrhea, and not at all in 2010. I’d ordered no tests, made no referrals. Had the insurer truly paid $1,800 for five office visits? If only.

With impressive efficiency, the insurer responded to my appeal within 4 hours:

Appeal denied. Your tier level will remain: Tier 2. No change in tier.

Explanations followed. Here are two of them:

"We have forwarded data which is not labeled because it is for patients from other plans. He would have to obtain the data from those plans to fill in the table." (Dismissing me in the third person was a nice touch.)

"The ETG’s group claims into categories and are not specific submitted diagnoses."

Perhaps the acronym, "ETG" is unfamiliar. You may know one of its other meanings: Emerging Technologies Group, Enhanced Target Generator, Evangelische Täufergemeinde. Here, however, it signifies "Episode Treatment Groups," undefined on the insurer’s spreadsheet but discoverable via Internet search as follows:

By combining related services into clinically homogenous units that describe complete episodes of care, ETGs may be utilized to provide the basis of valid comparisons. ETGs create episodes by collecting all inpatient, outpatient, and ancillary services into mutually exclusive and exhaustive categories.

Got that? In that case, can you tell me why another identified patient had solar keratoses, squamous cell carcinoma, and a cold sore – and an ETG classification of "Infection?" How clinically homogeneous, exclusive, and exhaustive is that? Or you can help me understand how a woman with herpes simplex incurred charges of $1,850 for five office visits. And when you’re done, you can explain what "Malignant neoplasm of the skin, major, w/o surgery" means. Although I asked that question directly, the insurer felt no obligation to tell me.

Challenging my appeal’s denial, I shot back an e-mail, which was of course ignored. Protocol had been followed. The case was closed. The medical director had spoken. I don’t know the man, but he must be a fan of Franz Kafka: indict the prisoner, order him to fill in his own charge sheet, but don’t tell him how. ("He would have to obtain the data [how?] from those plans [which plans?] to fill in the table." [It’s his table?])

Welcome to the future, dear colleagues. Our professional efforts will be increasingly judged from the inside of large black boxes, from the bowels of which statistical oracles will utter complex formulas they probably grasp as well as too-big-to-fail investment bankers understood derivatives trading.

The emperor, I submit, is wearing very little. No reason you should take my word for it, though. I’m only Tier 2.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these performance measures to rank doctors: the higher the tier, the lower the copay for patients.

Not too long ago, I crowed about being Tier 1. They say pride goes before a fall. Sometimes it goes before the spring.

An insurer who rated me Tier 1 for 2010 sent this year’s ratings. Tier 2. Demoted.

The shame!

But then I saw hope – I could appeal! I e-mailed a request for the data on which my designation was based. Promptly it came: a spreadsheet with 49 columns, plus A through Z, plus AA ... you get the picture. Reading down, there were 4,253 rows listing patients’ financial and demographic details. Across were headings like, "ACT_WT_PAID_TOT_AMT," explained elsewhere as, "Weighted actual payments for this ETG at peer rates."

Scanning screens of unfamiliar acronyms and tiny numbers (the spreadsheet was far too unwieldy to print out), I prepared my appeal. It had three main points:

– Only 47% of the patients showed names and dates of birth; the demographics for the rest were blank, making it impossible to check the data’s relevance and accuracy.

– Some categories made little or no sense. For instance, one ETG (see below) on which I had supposedly done well relative to peers was, "Malignant neoplasm of the skin, major, w/o surgery." What could major skin cancer without surgery possibly mean? An ETG on which I had done poorly was, "Malignant neoplasms of the skin, major, with surgery" – but 1,655 patients were classed as "Neoplasm of." Were these benign Neoplasms of? Malignant Neoplasms of? Major? Minor? W/ surgery? W/o? Who could know?

– One named patient I recognized was listed under the ETG "Infection." Line K, "weighted, actual payments," for this patient were $1,850.04 for 2009 (the "midpoint year.") I had seen this patient three times for oral herpes simplex in 2009, twice in 2008 for seborrhea, and not at all in 2010. I’d ordered no tests, made no referrals. Had the insurer truly paid $1,800 for five office visits? If only.

With impressive efficiency, the insurer responded to my appeal within 4 hours:

Appeal denied. Your tier level will remain: Tier 2. No change in tier.

Explanations followed. Here are two of them:

"We have forwarded data which is not labeled because it is for patients from other plans. He would have to obtain the data from those plans to fill in the table." (Dismissing me in the third person was a nice touch.)

"The ETG’s group claims into categories and are not specific submitted diagnoses."

Perhaps the acronym, "ETG" is unfamiliar. You may know one of its other meanings: Emerging Technologies Group, Enhanced Target Generator, Evangelische Täufergemeinde. Here, however, it signifies "Episode Treatment Groups," undefined on the insurer’s spreadsheet but discoverable via Internet search as follows:

By combining related services into clinically homogenous units that describe complete episodes of care, ETGs may be utilized to provide the basis of valid comparisons. ETGs create episodes by collecting all inpatient, outpatient, and ancillary services into mutually exclusive and exhaustive categories.

Got that? In that case, can you tell me why another identified patient had solar keratoses, squamous cell carcinoma, and a cold sore – and an ETG classification of "Infection?" How clinically homogeneous, exclusive, and exhaustive is that? Or you can help me understand how a woman with herpes simplex incurred charges of $1,850 for five office visits. And when you’re done, you can explain what "Malignant neoplasm of the skin, major, w/o surgery" means. Although I asked that question directly, the insurer felt no obligation to tell me.

Challenging my appeal’s denial, I shot back an e-mail, which was of course ignored. Protocol had been followed. The case was closed. The medical director had spoken. I don’t know the man, but he must be a fan of Franz Kafka: indict the prisoner, order him to fill in his own charge sheet, but don’t tell him how. ("He would have to obtain the data [how?] from those plans [which plans?] to fill in the table." [It’s his table?])

Welcome to the future, dear colleagues. Our professional efforts will be increasingly judged from the inside of large black boxes, from the bowels of which statistical oracles will utter complex formulas they probably grasp as well as too-big-to-fail investment bankers understood derivatives trading.

The emperor, I submit, is wearing very little. No reason you should take my word for it, though. I’m only Tier 2.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these performance measures to rank doctors: the higher the tier, the lower the copay for patients.

Not too long ago, I crowed about being Tier 1. They say pride goes before a fall. Sometimes it goes before the spring.

An insurer who rated me Tier 1 for 2010 sent this year’s ratings. Tier 2. Demoted.

The shame!

But then I saw hope – I could appeal! I e-mailed a request for the data on which my designation was based. Promptly it came: a spreadsheet with 49 columns, plus A through Z, plus AA ... you get the picture. Reading down, there were 4,253 rows listing patients’ financial and demographic details. Across were headings like, "ACT_WT_PAID_TOT_AMT," explained elsewhere as, "Weighted actual payments for this ETG at peer rates."

Scanning screens of unfamiliar acronyms and tiny numbers (the spreadsheet was far too unwieldy to print out), I prepared my appeal. It had three main points:

– Only 47% of the patients showed names and dates of birth; the demographics for the rest were blank, making it impossible to check the data’s relevance and accuracy.

– Some categories made little or no sense. For instance, one ETG (see below) on which I had supposedly done well relative to peers was, "Malignant neoplasm of the skin, major, w/o surgery." What could major skin cancer without surgery possibly mean? An ETG on which I had done poorly was, "Malignant neoplasms of the skin, major, with surgery" – but 1,655 patients were classed as "Neoplasm of." Were these benign Neoplasms of? Malignant Neoplasms of? Major? Minor? W/ surgery? W/o? Who could know?

– One named patient I recognized was listed under the ETG "Infection." Line K, "weighted, actual payments," for this patient were $1,850.04 for 2009 (the "midpoint year.") I had seen this patient three times for oral herpes simplex in 2009, twice in 2008 for seborrhea, and not at all in 2010. I’d ordered no tests, made no referrals. Had the insurer truly paid $1,800 for five office visits? If only.

With impressive efficiency, the insurer responded to my appeal within 4 hours:

Appeal denied. Your tier level will remain: Tier 2. No change in tier.

Explanations followed. Here are two of them:

"We have forwarded data which is not labeled because it is for patients from other plans. He would have to obtain the data from those plans to fill in the table." (Dismissing me in the third person was a nice touch.)

"The ETG’s group claims into categories and are not specific submitted diagnoses."

Perhaps the acronym, "ETG" is unfamiliar. You may know one of its other meanings: Emerging Technologies Group, Enhanced Target Generator, Evangelische Täufergemeinde. Here, however, it signifies "Episode Treatment Groups," undefined on the insurer’s spreadsheet but discoverable via Internet search as follows:

By combining related services into clinically homogenous units that describe complete episodes of care, ETGs may be utilized to provide the basis of valid comparisons. ETGs create episodes by collecting all inpatient, outpatient, and ancillary services into mutually exclusive and exhaustive categories.

Got that? In that case, can you tell me why another identified patient had solar keratoses, squamous cell carcinoma, and a cold sore – and an ETG classification of "Infection?" How clinically homogeneous, exclusive, and exhaustive is that? Or you can help me understand how a woman with herpes simplex incurred charges of $1,850 for five office visits. And when you’re done, you can explain what "Malignant neoplasm of the skin, major, w/o surgery" means. Although I asked that question directly, the insurer felt no obligation to tell me.

Challenging my appeal’s denial, I shot back an e-mail, which was of course ignored. Protocol had been followed. The case was closed. The medical director had spoken. I don’t know the man, but he must be a fan of Franz Kafka: indict the prisoner, order him to fill in his own charge sheet, but don’t tell him how. ("He would have to obtain the data [how?] from those plans [which plans?] to fill in the table." [It’s his table?])

Welcome to the future, dear colleagues. Our professional efforts will be increasingly judged from the inside of large black boxes, from the bowels of which statistical oracles will utter complex formulas they probably grasp as well as too-big-to-fail investment bankers understood derivatives trading.

The emperor, I submit, is wearing very little. No reason you should take my word for it, though. I’m only Tier 2.

"Who gave you my name?" I asked.

"I found you on the Internet. I read your reviews."

More and more patients say things like this to me, so I Googled my reviews. Here's one:

"This guy gave me a 5 minute appointment. He did not listen to anything I had to say. I recommend NOT going to see him. Absolutely awful. Please, please don't waste your money."

Maybe you're thinking: "It's just cranky people who vent online. I'm sure Rockoff probably doesn't blow people off like that." If so, you are kind. Thanks.

But how do you really know? Maybe I do ignore what patients have to say. Or maybe I usually don't but did this time. Here's another review:

"This doctor was a total waste of time. I go in and explain my problem, explain my pains. He proceeds to tell me that it is all in my head, and the pain is because I am thinking about having pain. REALLY? I spend my time trying to imagine pain? Please, PLEASE do not go to this doctor."

I like to think I counsel more sensitively than that, but maybe I didn't at this visit. Since the review is anonymous, I really don't know.

Online reviews are a fact of life. Authors I know ask friends to plug their work on Amazon. I once chose a beard trimmer based on an online review. (I hate the trimmer but don't have the time, or bile, to share this with the hirsute universe.)

When it comes to reviews, legal experts tell us that we lack recourse to address egregious, even libelous, attacks on our professional competence, including those that could threaten our reputation and livelihood. Anonymity makes attacking easy and painless to the attacker.

"The three times I went he rushed the appointment, told me the wrong information regarding my skin problem, and was visibly (sic) upset when I tried to ask questions to understand what was wrong with my skin which if he explained it properly ..."

That isn't how I think I interact with people, but maybe I'm wrong. After all, offensive people mostly don't notice that they're obnoxious. Perhaps this patient and I just didn't hit it off. If you deal with a lot of people, a few of them won't like you. There is nothing new there.

But before the Internet, patients who disliked you just complained to a few friends and asked you for their records. Now they can vent their spleen and post it to all humanity.

I think most doctors are ingratiating sorts. Unlike litigating attorneys or meter maids, we generally want people to like us. Even if we know not everyone will, it bothers us when they don't. We sometimes give a passing thought to the way we'll be remembered, to the extent that we are. We may hope that people will recall us as someone who cared and tried to help, even if we sometimes fell short, or failed.

Online reviews ensure that critiques of these failures, justified or not, become an enduring part of the public record. Imagine if this were true of personal relationships: if every relative we riled up, every friend we let down, or every neighbor we crossed could spend 5 delicious minutes getting even by assassinating our character for the whole world for all time. And anonymously - what bliss!

Online reviews are not going away, so whining about them is about as useful as complaining that air has too much nitrogen. One helpful strategy is to actively solicit positive reviews. I admit this goes against my grain, but you have to move with the times. Happy patients will gladly post comments if you ask them. I did this last week. Here's the review:

"At a recent visit, I left waiting to hear back for results from a biopsy. Upon leaving, albeit a bit nervous, I thought about how assured I feel every time I meet with Dr. Rockoff. I know if I have to hear something dreadful, I would prefer to hear it from him."

Nice, yes? I may be Dr. Doom, but I do it with a smile.

Of course, the other reviews will remain, diluted but unexpunged. Oh, well. Keeps you honest anyway.

"Who gave you my name?" I asked.

"I found you on the Internet. I read your reviews."

More and more patients say things like this to me, so I Googled my reviews. Here's one:

"This guy gave me a 5 minute appointment. He did not listen to anything I had to say. I recommend NOT going to see him. Absolutely awful. Please, please don't waste your money."

Maybe you're thinking: "It's just cranky people who vent online. I'm sure Rockoff probably doesn't blow people off like that." If so, you are kind. Thanks.

But how do you really know? Maybe I do ignore what patients have to say. Or maybe I usually don't but did this time. Here's another review:

"This doctor was a total waste of time. I go in and explain my problem, explain my pains. He proceeds to tell me that it is all in my head, and the pain is because I am thinking about having pain. REALLY? I spend my time trying to imagine pain? Please, PLEASE do not go to this doctor."

I like to think I counsel more sensitively than that, but maybe I didn't at this visit. Since the review is anonymous, I really don't know.

Online reviews are a fact of life. Authors I know ask friends to plug their work on Amazon. I once chose a beard trimmer based on an online review. (I hate the trimmer but don't have the time, or bile, to share this with the hirsute universe.)

When it comes to reviews, legal experts tell us that we lack recourse to address egregious, even libelous, attacks on our professional competence, including those that could threaten our reputation and livelihood. Anonymity makes attacking easy and painless to the attacker.

"The three times I went he rushed the appointment, told me the wrong information regarding my skin problem, and was visibly (sic) upset when I tried to ask questions to understand what was wrong with my skin which if he explained it properly ..."

That isn't how I think I interact with people, but maybe I'm wrong. After all, offensive people mostly don't notice that they're obnoxious. Perhaps this patient and I just didn't hit it off. If you deal with a lot of people, a few of them won't like you. There is nothing new there.

But before the Internet, patients who disliked you just complained to a few friends and asked you for their records. Now they can vent their spleen and post it to all humanity.

I think most doctors are ingratiating sorts. Unlike litigating attorneys or meter maids, we generally want people to like us. Even if we know not everyone will, it bothers us when they don't. We sometimes give a passing thought to the way we'll be remembered, to the extent that we are. We may hope that people will recall us as someone who cared and tried to help, even if we sometimes fell short, or failed.

Online reviews ensure that critiques of these failures, justified or not, become an enduring part of the public record. Imagine if this were true of personal relationships: if every relative we riled up, every friend we let down, or every neighbor we crossed could spend 5 delicious minutes getting even by assassinating our character for the whole world for all time. And anonymously - what bliss!

Online reviews are not going away, so whining about them is about as useful as complaining that air has too much nitrogen. One helpful strategy is to actively solicit positive reviews. I admit this goes against my grain, but you have to move with the times. Happy patients will gladly post comments if you ask them. I did this last week. Here's the review:

"At a recent visit, I left waiting to hear back for results from a biopsy. Upon leaving, albeit a bit nervous, I thought about how assured I feel every time I meet with Dr. Rockoff. I know if I have to hear something dreadful, I would prefer to hear it from him."

Nice, yes? I may be Dr. Doom, but I do it with a smile.

Of course, the other reviews will remain, diluted but unexpunged. Oh, well. Keeps you honest anyway.

"Who gave you my name?" I asked.

"I found you on the Internet. I read your reviews."

More and more patients say things like this to me, so I Googled my reviews. Here's one:

"This guy gave me a 5 minute appointment. He did not listen to anything I had to say. I recommend NOT going to see him. Absolutely awful. Please, please don't waste your money."

Maybe you're thinking: "It's just cranky people who vent online. I'm sure Rockoff probably doesn't blow people off like that." If so, you are kind. Thanks.

But how do you really know? Maybe I do ignore what patients have to say. Or maybe I usually don't but did this time. Here's another review:

"This doctor was a total waste of time. I go in and explain my problem, explain my pains. He proceeds to tell me that it is all in my head, and the pain is because I am thinking about having pain. REALLY? I spend my time trying to imagine pain? Please, PLEASE do not go to this doctor."

I like to think I counsel more sensitively than that, but maybe I didn't at this visit. Since the review is anonymous, I really don't know.

Online reviews are a fact of life. Authors I know ask friends to plug their work on Amazon. I once chose a beard trimmer based on an online review. (I hate the trimmer but don't have the time, or bile, to share this with the hirsute universe.)

When it comes to reviews, legal experts tell us that we lack recourse to address egregious, even libelous, attacks on our professional competence, including those that could threaten our reputation and livelihood. Anonymity makes attacking easy and painless to the attacker.

"The three times I went he rushed the appointment, told me the wrong information regarding my skin problem, and was visibly (sic) upset when I tried to ask questions to understand what was wrong with my skin which if he explained it properly ..."

That isn't how I think I interact with people, but maybe I'm wrong. After all, offensive people mostly don't notice that they're obnoxious. Perhaps this patient and I just didn't hit it off. If you deal with a lot of people, a few of them won't like you. There is nothing new there.

But before the Internet, patients who disliked you just complained to a few friends and asked you for their records. Now they can vent their spleen and post it to all humanity.

I think most doctors are ingratiating sorts. Unlike litigating attorneys or meter maids, we generally want people to like us. Even if we know not everyone will, it bothers us when they don't. We sometimes give a passing thought to the way we'll be remembered, to the extent that we are. We may hope that people will recall us as someone who cared and tried to help, even if we sometimes fell short, or failed.

Online reviews ensure that critiques of these failures, justified or not, become an enduring part of the public record. Imagine if this were true of personal relationships: if every relative we riled up, every friend we let down, or every neighbor we crossed could spend 5 delicious minutes getting even by assassinating our character for the whole world for all time. And anonymously - what bliss!

Online reviews are not going away, so whining about them is about as useful as complaining that air has too much nitrogen. One helpful strategy is to actively solicit positive reviews. I admit this goes against my grain, but you have to move with the times. Happy patients will gladly post comments if you ask them. I did this last week. Here's the review:

"At a recent visit, I left waiting to hear back for results from a biopsy. Upon leaving, albeit a bit nervous, I thought about how assured I feel every time I meet with Dr. Rockoff. I know if I have to hear something dreadful, I would prefer to hear it from him."

Nice, yes? I may be Dr. Doom, but I do it with a smile.

Of course, the other reviews will remain, diluted but unexpunged. Oh, well. Keeps you honest anyway.

I'm finally ready to go back to work," said Jim, a burly, middle-aged man in for his annual skin check. "I had bypass surgery 2 months ago.

"It's funny," he continued. "I didn't have any chest pain, just overwhelming fatigue. I used to be a firefighter, but now I go around the country lecturing on terrorism and security. When I was in California for a 3-day gig, I got too weak to stand, so I went home after a day.

"My doctor ran all kinds of tests and found no problems. Then he sent me to a cardiologist who examined me and did an ultrasound and a stress test. Nothing. My primary asked for a cardiac catheterization, but the cardiologist said no. 'That would be a waste of everyone's time and money,' the cardiologist told us, 'and there are risks,' she said. But my doctor insisted. The catheterization showed a serious blockage, which they repaired."

"And the fatigue?" I asked him.

"Gone," said Jim.

"What did the cardiologist say when she found the blockage?" I asked.

"Let's just say I had my records forwarded to another heart specialist," he replied.

When Jim left, I told my student that some cases are so interesting, you can't learn anything from them.

As if to confirm my observation, the very next day Mary walks in for her annual. "I hope this year is better healthwise," she said. "Last year was pretty bad."

"What happened?" I asked.

"Several things," said Mary, "but the worst was colon cancer."

"How did they discover that?" I asked her.

"I went in to my doctor and told him, 'I look like a cancer patient.'"

What?

"It's hard to put a finger on," she said. "I just didn't look right."

"Did you lose weight? Were you tired?"

"No, I felt fine," said Mary. "I just thought I looked like I had cancer. So I asked my doctor for a colonoscopy. He said, 'It's not time.' But I said I wanted one anyway. So he had it scheduled. Sure enough, they found cancer and took it out. I look much better now."

I wished Mary an uneventful year.

Not every tale has a moral. What can we learn from Jim's and Mary's? That we don't always get it right? We know that. That sometimes patients make observations and share hunches about their bodies worth paying attention to? Sure. That we should give in to demands for catheterizations and colonoscopies when there aren't any signs, symptoms, or clinical indications? Really?

It's interesting that both Jim and Mary told their tales in a doctor's office about a medical profession they apparently still trust; they could have concluded instead that the so-called experts don't know what they're talking about.

Imagine the same testimonies in a different setting. Say a lay group gathered to challenge the conventional medical establishment, one they see as blinded by limited perspective, deaf to what people know about their own bodies, insensitive to patients who advocate for themselves. Hearing these stories, wouldn't everybody in attendance nod in agreement and share their disapproval of what these stories so clearly seem to show, namely that doctors don't listen?

Personal anecdotes have great power, though of course they prove nothing even if told accurately. But what can we really do with them? Do we ever see patients who think they have cancer? Who report fleeting rashes and funny sensations that scare them? Should we biopsy them all, just in case? Run blood tests and x-rays?
Years ago one of my closest friends complained of itch with no rash. It turns out she had primary biliary cirrhosis and died 9 years later after her second liver transplant.

Since then I've seen more than a few itchy patients. Not one has had liver disease.
I am happy things turned out well for Jim and Mary and glad (though surprised) that their doctors followed through on their requests. I'm even more amazed that their insurers approved the requested tests. Imagine putting through this prior authorization: "I recommend this because the patient and I are sure it's the right thing." Now imagine the uproarious laughter in the insurer's office.

Stories are always worth listening to and thinking about. Jim's and Mary's certainly are. I just don't know if I learned anything useful from them.

I'm finally ready to go back to work," said Jim, a burly, middle-aged man in for his annual skin check. "I had bypass surgery 2 months ago.

"It's funny," he continued. "I didn't have any chest pain, just overwhelming fatigue. I used to be a firefighter, but now I go around the country lecturing on terrorism and security. When I was in California for a 3-day gig, I got too weak to stand, so I went home after a day.

"My doctor ran all kinds of tests and found no problems. Then he sent me to a cardiologist who examined me and did an ultrasound and a stress test. Nothing. My primary asked for a cardiac catheterization, but the cardiologist said no. 'That would be a waste of everyone's time and money,' the cardiologist told us, 'and there are risks,' she said. But my doctor insisted. The catheterization showed a serious blockage, which they repaired."

"And the fatigue?" I asked him.

"Gone," said Jim.

"What did the cardiologist say when she found the blockage?" I asked.

"Let's just say I had my records forwarded to another heart specialist," he replied.

When Jim left, I told my student that some cases are so interesting, you can't learn anything from them.

As if to confirm my observation, the very next day Mary walks in for her annual. "I hope this year is better healthwise," she said. "Last year was pretty bad."

"What happened?" I asked.

"Several things," said Mary, "but the worst was colon cancer."

"How did they discover that?" I asked her.

"I went in to my doctor and told him, 'I look like a cancer patient.'"

What?

"It's hard to put a finger on," she said. "I just didn't look right."

"Did you lose weight? Were you tired?"

"No, I felt fine," said Mary. "I just thought I looked like I had cancer. So I asked my doctor for a colonoscopy. He said, 'It's not time.' But I said I wanted one anyway. So he had it scheduled. Sure enough, they found cancer and took it out. I look much better now."

I wished Mary an uneventful year.

Not every tale has a moral. What can we learn from Jim's and Mary's? That we don't always get it right? We know that. That sometimes patients make observations and share hunches about their bodies worth paying attention to? Sure. That we should give in to demands for catheterizations and colonoscopies when there aren't any signs, symptoms, or clinical indications? Really?

It's interesting that both Jim and Mary told their tales in a doctor's office about a medical profession they apparently still trust; they could have concluded instead that the so-called experts don't know what they're talking about.

Imagine the same testimonies in a different setting. Say a lay group gathered to challenge the conventional medical establishment, one they see as blinded by limited perspective, deaf to what people know about their own bodies, insensitive to patients who advocate for themselves. Hearing these stories, wouldn't everybody in attendance nod in agreement and share their disapproval of what these stories so clearly seem to show, namely that doctors don't listen?

Personal anecdotes have great power, though of course they prove nothing even if told accurately. But what can we really do with them? Do we ever see patients who think they have cancer? Who report fleeting rashes and funny sensations that scare them? Should we biopsy them all, just in case? Run blood tests and x-rays?
Years ago one of my closest friends complained of itch with no rash. It turns out she had primary biliary cirrhosis and died 9 years later after her second liver transplant.

Since then I've seen more than a few itchy patients. Not one has had liver disease.
I am happy things turned out well for Jim and Mary and glad (though surprised) that their doctors followed through on their requests. I'm even more amazed that their insurers approved the requested tests. Imagine putting through this prior authorization: "I recommend this because the patient and I are sure it's the right thing." Now imagine the uproarious laughter in the insurer's office.

Stories are always worth listening to and thinking about. Jim's and Mary's certainly are. I just don't know if I learned anything useful from them.

I'm finally ready to go back to work," said Jim, a burly, middle-aged man in for his annual skin check. "I had bypass surgery 2 months ago.

"It's funny," he continued. "I didn't have any chest pain, just overwhelming fatigue. I used to be a firefighter, but now I go around the country lecturing on terrorism and security. When I was in California for a 3-day gig, I got too weak to stand, so I went home after a day.

"My doctor ran all kinds of tests and found no problems. Then he sent me to a cardiologist who examined me and did an ultrasound and a stress test. Nothing. My primary asked for a cardiac catheterization, but the cardiologist said no. 'That would be a waste of everyone's time and money,' the cardiologist told us, 'and there are risks,' she said. But my doctor insisted. The catheterization showed a serious blockage, which they repaired."

"And the fatigue?" I asked him.

"Gone," said Jim.

"What did the cardiologist say when she found the blockage?" I asked.

"Let's just say I had my records forwarded to another heart specialist," he replied.

When Jim left, I told my student that some cases are so interesting, you can't learn anything from them.

As if to confirm my observation, the very next day Mary walks in for her annual. "I hope this year is better healthwise," she said. "Last year was pretty bad."

"What happened?" I asked.

"Several things," said Mary, "but the worst was colon cancer."

"How did they discover that?" I asked her.

"I went in to my doctor and told him, 'I look like a cancer patient.'"

What?

"It's hard to put a finger on," she said. "I just didn't look right."

"Did you lose weight? Were you tired?"

"No, I felt fine," said Mary. "I just thought I looked like I had cancer. So I asked my doctor for a colonoscopy. He said, 'It's not time.' But I said I wanted one anyway. So he had it scheduled. Sure enough, they found cancer and took it out. I look much better now."

I wished Mary an uneventful year.

Not every tale has a moral. What can we learn from Jim's and Mary's? That we don't always get it right? We know that. That sometimes patients make observations and share hunches about their bodies worth paying attention to? Sure. That we should give in to demands for catheterizations and colonoscopies when there aren't any signs, symptoms, or clinical indications? Really?

It's interesting that both Jim and Mary told their tales in a doctor's office about a medical profession they apparently still trust; they could have concluded instead that the so-called experts don't know what they're talking about.

Imagine the same testimonies in a different setting. Say a lay group gathered to challenge the conventional medical establishment, one they see as blinded by limited perspective, deaf to what people know about their own bodies, insensitive to patients who advocate for themselves. Hearing these stories, wouldn't everybody in attendance nod in agreement and share their disapproval of what these stories so clearly seem to show, namely that doctors don't listen?

Personal anecdotes have great power, though of course they prove nothing even if told accurately. But what can we really do with them? Do we ever see patients who think they have cancer? Who report fleeting rashes and funny sensations that scare them? Should we biopsy them all, just in case? Run blood tests and x-rays?
Years ago one of my closest friends complained of itch with no rash. It turns out she had primary biliary cirrhosis and died 9 years later after her second liver transplant.

Since then I've seen more than a few itchy patients. Not one has had liver disease.
I am happy things turned out well for Jim and Mary and glad (though surprised) that their doctors followed through on their requests. I'm even more amazed that their insurers approved the requested tests. Imagine putting through this prior authorization: "I recommend this because the patient and I are sure it's the right thing." Now imagine the uproarious laughter in the insurer's office.

Stories are always worth listening to and thinking about. Jim's and Mary's certainly are. I just don't know if I learned anything useful from them.

You only hear what you listen for.

When people say things that seem to make no sense, our natural reaction is to ignore the statements or let them pass unnoticed. But filtering out seemingly nonsensical remarks from patients can be a mistake, because offhand comments reveal a lot about how they see the world, which is often quite different from the way we see things.

Consider Harriet: "My mole changed because it's near my bra strap," she said.
The mole is irregular, not irritated, so why does Harriet think her bra had anything to do with it? When I asked my students this question, they looked blank. "Did she really say that?" they asked. They didn’t really hear my question, because the statement made no sense to them.

But it made sense to Harriet. What she meant to say was: "Trauma causes cancer." Of course we know that trauma does not cause cancer, but Harriet thinks it does, and she has a lot of company.

"These spots on my nose came when my face hit a window," said Bill. Does it matter if he believes this?

Consider Cindy: "My brother picked at a spot on his cheek, and he died," she said. Yes, people really do say things like this, all the time. You just have to listen for them. Here is what else they say:

"Does Fiona have to take extra precautions in the sun for the moles on her back by covering them up?" asked her mother. Why did she ask this? Because sunburn is a form of trauma, and everybody knows what trauma can do. So what if she thinks this, right?

She insisted that Fiona cover her moles with bandages at the beach. Sound silly? Fiona’s mother didn’t think so. Ask her. Better still, volunteer that Fiona can stop putting bandages on her moles, and watch mom beam with relief or astonishment. "But that’s what I've been doing!" exclaimed Fiona.

Then, there is  Barry: "I think I'm getting acne because of the water at my new school." Barry is from Chicago. At this very moment in Chicago, another Barry – from Boston – is telling his dermatologist that it must be the Midwestern water. Why do they each think so?

"The water” (or "the air," or "the atmosphere," or "the environment") has explained disease since Hippocrates. Everybody knows this. You can hear them say so, if you listen.

"It's the weather," they say, or the change of seasons, or the power lines.
Or take Gerrold, who had a cluster of bumps on his left elbow and knew why: "The pustules on my arm are my body trying to get rid of something." How's that? What is your body trying to get rid of?

It seems his body was trying to expel evil,  noxious stuff, just as it does when eliminating other unpleasant body fluids. These include sebum, which is why so many work so hard to cleanse their pores. We must get that bad stuff out.
"Tell me," I asked my student, "why the last patient said his cherry angioma is gross?"

"Did he say that?" asked the student, looking perplexed.

He did. The student didn't hear him, because there seems to be no room for the word "disgusting" in a medical interaction. A lesion can be benign or malignant, but not disgusting. Yet the patient, a middle-aged electrician, said, "When I was leaving the house to come here, my kids said, 'Dad, get rid of that gross thing!' "

So did Paula, a 20-something concerned with a bump on her scalp. "My boyfriend said, 'That’s disgusting!' " I told Paula it was a benign mole. "Maybe so," she said, "but it's disgusting."

The question is not whether we need to agree that skin irregularities are repugnant, but why patients announce they think so. They say this not just about oozing or contagious dermatoses but about harmless lumps and bumps. Why?

Perhaps these spontaneous outbursts of distaste tell us that what people think about skin problems goes beyond functional disability, and that distinctions between "medical" and "cosmetic" can be arbitrary and beside the point.

That may not be very meaningful to us, but like everything else we ought to know about patients,  it makes a lot of sense to them. They tell us so over and over. But to hear them, we need to listen between the lines.

You only hear what you listen for.

When people say things that seem to make no sense, our natural reaction is to ignore the statements or let them pass unnoticed. But filtering out seemingly nonsensical remarks from patients can be a mistake, because offhand comments reveal a lot about how they see the world, which is often quite different from the way we see things.

Consider Harriet: "My mole changed because it's near my bra strap," she said.
The mole is irregular, not irritated, so why does Harriet think her bra had anything to do with it? When I asked my students this question, they looked blank. "Did she really say that?" they asked. They didn’t really hear my question, because the statement made no sense to them.

But it made sense to Harriet. What she meant to say was: "Trauma causes cancer." Of course we know that trauma does not cause cancer, but Harriet thinks it does, and she has a lot of company.

"These spots on my nose came when my face hit a window," said Bill. Does it matter if he believes this?

Consider Cindy: "My brother picked at a spot on his cheek, and he died," she said. Yes, people really do say things like this, all the time. You just have to listen for them. Here is what else they say:

"Does Fiona have to take extra precautions in the sun for the moles on her back by covering them up?" asked her mother. Why did she ask this? Because sunburn is a form of trauma, and everybody knows what trauma can do. So what if she thinks this, right?

She insisted that Fiona cover her moles with bandages at the beach. Sound silly? Fiona’s mother didn’t think so. Ask her. Better still, volunteer that Fiona can stop putting bandages on her moles, and watch mom beam with relief or astonishment. "But that’s what I've been doing!" exclaimed Fiona.

Then, there is  Barry: "I think I'm getting acne because of the water at my new school." Barry is from Chicago. At this very moment in Chicago, another Barry – from Boston – is telling his dermatologist that it must be the Midwestern water. Why do they each think so?

"The water” (or "the air," or "the atmosphere," or "the environment") has explained disease since Hippocrates. Everybody knows this. You can hear them say so, if you listen.

"It's the weather," they say, or the change of seasons, or the power lines.
Or take Gerrold, who had a cluster of bumps on his left elbow and knew why: "The pustules on my arm are my body trying to get rid of something." How's that? What is your body trying to get rid of?

It seems his body was trying to expel evil,  noxious stuff, just as it does when eliminating other unpleasant body fluids. These include sebum, which is why so many work so hard to cleanse their pores. We must get that bad stuff out.
"Tell me," I asked my student, "why the last patient said his cherry angioma is gross?"

"Did he say that?" asked the student, looking perplexed.

He did. The student didn't hear him, because there seems to be no room for the word "disgusting" in a medical interaction. A lesion can be benign or malignant, but not disgusting. Yet the patient, a middle-aged electrician, said, "When I was leaving the house to come here, my kids said, 'Dad, get rid of that gross thing!' "

So did Paula, a 20-something concerned with a bump on her scalp. "My boyfriend said, 'That’s disgusting!' " I told Paula it was a benign mole. "Maybe so," she said, "but it's disgusting."

The question is not whether we need to agree that skin irregularities are repugnant, but why patients announce they think so. They say this not just about oozing or contagious dermatoses but about harmless lumps and bumps. Why?

Perhaps these spontaneous outbursts of distaste tell us that what people think about skin problems goes beyond functional disability, and that distinctions between "medical" and "cosmetic" can be arbitrary and beside the point.

That may not be very meaningful to us, but like everything else we ought to know about patients,  it makes a lot of sense to them. They tell us so over and over. But to hear them, we need to listen between the lines.

You only hear what you listen for.

When people say things that seem to make no sense, our natural reaction is to ignore the statements or let them pass unnoticed. But filtering out seemingly nonsensical remarks from patients can be a mistake, because offhand comments reveal a lot about how they see the world, which is often quite different from the way we see things.

Consider Harriet: "My mole changed because it's near my bra strap," she said.
The mole is irregular, not irritated, so why does Harriet think her bra had anything to do with it? When I asked my students this question, they looked blank. "Did she really say that?" they asked. They didn’t really hear my question, because the statement made no sense to them.

But it made sense to Harriet. What she meant to say was: "Trauma causes cancer." Of course we know that trauma does not cause cancer, but Harriet thinks it does, and she has a lot of company.

"These spots on my nose came when my face hit a window," said Bill. Does it matter if he believes this?

Consider Cindy: "My brother picked at a spot on his cheek, and he died," she said. Yes, people really do say things like this, all the time. You just have to listen for them. Here is what else they say:

"Does Fiona have to take extra precautions in the sun for the moles on her back by covering them up?" asked her mother. Why did she ask this? Because sunburn is a form of trauma, and everybody knows what trauma can do. So what if she thinks this, right?

She insisted that Fiona cover her moles with bandages at the beach. Sound silly? Fiona’s mother didn’t think so. Ask her. Better still, volunteer that Fiona can stop putting bandages on her moles, and watch mom beam with relief or astonishment. "But that’s what I've been doing!" exclaimed Fiona.

Then, there is  Barry: "I think I'm getting acne because of the water at my new school." Barry is from Chicago. At this very moment in Chicago, another Barry – from Boston – is telling his dermatologist that it must be the Midwestern water. Why do they each think so?

"The water” (or "the air," or "the atmosphere," or "the environment") has explained disease since Hippocrates. Everybody knows this. You can hear them say so, if you listen.

"It's the weather," they say, or the change of seasons, or the power lines.
Or take Gerrold, who had a cluster of bumps on his left elbow and knew why: "The pustules on my arm are my body trying to get rid of something." How's that? What is your body trying to get rid of?

It seems his body was trying to expel evil,  noxious stuff, just as it does when eliminating other unpleasant body fluids. These include sebum, which is why so many work so hard to cleanse their pores. We must get that bad stuff out.
"Tell me," I asked my student, "why the last patient said his cherry angioma is gross?"

"Did he say that?" asked the student, looking perplexed.

He did. The student didn't hear him, because there seems to be no room for the word "disgusting" in a medical interaction. A lesion can be benign or malignant, but not disgusting. Yet the patient, a middle-aged electrician, said, "When I was leaving the house to come here, my kids said, 'Dad, get rid of that gross thing!' "

So did Paula, a 20-something concerned with a bump on her scalp. "My boyfriend said, 'That’s disgusting!' " I told Paula it was a benign mole. "Maybe so," she said, "but it's disgusting."

The question is not whether we need to agree that skin irregularities are repugnant, but why patients announce they think so. They say this not just about oozing or contagious dermatoses but about harmless lumps and bumps. Why?

Perhaps these spontaneous outbursts of distaste tell us that what people think about skin problems goes beyond functional disability, and that distinctions between "medical" and "cosmetic" can be arbitrary and beside the point.

That may not be very meaningful to us, but like everything else we ought to know about patients,  it makes a lot of sense to them. They tell us so over and over. But to hear them, we need to listen between the lines.

"You’re magic," she said. "As soon as I made the appointment, my rash went away!"

I smiled noncommittally. I didn't want to break the spell.

"I got this rash on my bottom," she explained. "I showed it to my primary care physician and he said, 'That looks bad! You’d better see a surgeon.' "

"So I went to the surgeon and showed him the rash. 'That looks bad!' he said, 'but it sure doesn't need surgery. That's a fungus infection.' So he gave me a cream.” She held out a tube of nystatin.

"I used it for 2 weeks but it didn't help," she went on, "so I went back to the surgeon. 'That's a really bad infection,' he said. 'Use more of the cream.' "

"I kept using the cream but the rash still didn't get better. Then my husband said, 'Didn't that Rockoff fellow prescribe a cream for you a couple of years ago?' "

She showed me a tube of desonide. "You said I could use it on my face and my bottom," she said, "and it cleared me right up. Isn’t that amazing?"

I agreed that it was and had a look. The rash was gone.

Concerning her case, I had little to discuss clinically with my student. He already knew that not every groin rash is fungal, but he also knew that in the greater world the default diagnosis is that every rash is probably a fungus, even if the cream often prescribed is anti-yeast. What interested me was this patient's attitude toward her experience, marked by gratitude, even wonder, rather than the irritation and resentment she might have expressed.

She could have said: “How come my primary doctor didn't know what this was and thought I needed surgery? Why did the surgeon think it was a fungus, and when I said the fungus cream wasn't working, why did he tell me to use even more of it? Why did it take my husband to get it right?"

But she did not say any of these things, she didn't even think them. Even when she referred to the time and "hundreds of dollars" the doctor's visits and creams took, there was nothing in her tone to suggest she was biting her tongue. She was just delighted that everything had worked out.

We often complain that patients don't cut us enough slack. If things didn't work out as well as they wished, as fast as they expected, or if we kept them waiting longer than they wanted – whether or not any of this was within our control – they let us know loud and clear that we haven't measured up.

Letting off steam from time to time about patients and frustrations is fair enough, but it’s worth reflecting on how many patients cut us plenty of slack, perhaps more than they should. I’m sometimes bemused, for instance, when I see a new acne patient who has just moved to the area. I ask him what he's been treated with.

"Minocycline."

"How long?"

"Three years."

"Is it working?"

"No."

"So what did the doctor say when you came back to see him?"

"Keep taking the minocycline."

Considering the people who call us every 3 days to complain that their pimples aren't going away, how do we explain why this gentleman (or his mother) didn't ask, "Say, doc, haven't you got anything else?"

Challenging an authority figure is not easy for most people. Many are reluctant to do so, if for no other reason than if they don't trust the person they're asking advice from, where exactly does that leave them?

And so many patients have so much trust and confidence in us that they overlook – or don't notice – if we fail to get the diagnosis right the first (or second) time, if the medication we prescribed had a side effect we didn't tell them about, or if it cost them a bundle because their insurance covered less than we figured.

The truth is that most patients cut us plenty of slack. Sometimes more than we deserve

"You’re magic," she said. "As soon as I made the appointment, my rash went away!"

I smiled noncommittally. I didn't want to break the spell.

"I got this rash on my bottom," she explained. "I showed it to my primary care physician and he said, 'That looks bad! You’d better see a surgeon.' "

"So I went to the surgeon and showed him the rash. 'That looks bad!' he said, 'but it sure doesn't need surgery. That's a fungus infection.' So he gave me a cream.” She held out a tube of nystatin.

"I used it for 2 weeks but it didn't help," she went on, "so I went back to the surgeon. 'That's a really bad infection,' he said. 'Use more of the cream.' "

"I kept using the cream but the rash still didn't get better. Then my husband said, 'Didn't that Rockoff fellow prescribe a cream for you a couple of years ago?' "

She showed me a tube of desonide. "You said I could use it on my face and my bottom," she said, "and it cleared me right up. Isn’t that amazing?"

I agreed that it was and had a look. The rash was gone.

Concerning her case, I had little to discuss clinically with my student. He already knew that not every groin rash is fungal, but he also knew that in the greater world the default diagnosis is that every rash is probably a fungus, even if the cream often prescribed is anti-yeast. What interested me was this patient's attitude toward her experience, marked by gratitude, even wonder, rather than the irritation and resentment she might have expressed.

She could have said: “How come my primary doctor didn't know what this was and thought I needed surgery? Why did the surgeon think it was a fungus, and when I said the fungus cream wasn't working, why did he tell me to use even more of it? Why did it take my husband to get it right?"

But she did not say any of these things, she didn't even think them. Even when she referred to the time and "hundreds of dollars" the doctor's visits and creams took, there was nothing in her tone to suggest she was biting her tongue. She was just delighted that everything had worked out.

We often complain that patients don't cut us enough slack. If things didn't work out as well as they wished, as fast as they expected, or if we kept them waiting longer than they wanted – whether or not any of this was within our control – they let us know loud and clear that we haven't measured up.

Letting off steam from time to time about patients and frustrations is fair enough, but it’s worth reflecting on how many patients cut us plenty of slack, perhaps more than they should. I’m sometimes bemused, for instance, when I see a new acne patient who has just moved to the area. I ask him what he's been treated with.

"Minocycline."

"How long?"

"Three years."

"Is it working?"

"No."

"So what did the doctor say when you came back to see him?"

"Keep taking the minocycline."

Considering the people who call us every 3 days to complain that their pimples aren't going away, how do we explain why this gentleman (or his mother) didn't ask, "Say, doc, haven't you got anything else?"

Challenging an authority figure is not easy for most people. Many are reluctant to do so, if for no other reason than if they don't trust the person they're asking advice from, where exactly does that leave them?

And so many patients have so much trust and confidence in us that they overlook – or don't notice – if we fail to get the diagnosis right the first (or second) time, if the medication we prescribed had a side effect we didn't tell them about, or if it cost them a bundle because their insurance covered less than we figured.

The truth is that most patients cut us plenty of slack. Sometimes more than we deserve

"You’re magic," she said. "As soon as I made the appointment, my rash went away!"

I smiled noncommittally. I didn't want to break the spell.

"I got this rash on my bottom," she explained. "I showed it to my primary care physician and he said, 'That looks bad! You’d better see a surgeon.' "

"So I went to the surgeon and showed him the rash. 'That looks bad!' he said, 'but it sure doesn't need surgery. That's a fungus infection.' So he gave me a cream.” She held out a tube of nystatin.

"I used it for 2 weeks but it didn't help," she went on, "so I went back to the surgeon. 'That's a really bad infection,' he said. 'Use more of the cream.' "

"I kept using the cream but the rash still didn't get better. Then my husband said, 'Didn't that Rockoff fellow prescribe a cream for you a couple of years ago?' "

She showed me a tube of desonide. "You said I could use it on my face and my bottom," she said, "and it cleared me right up. Isn’t that amazing?"

I agreed that it was and had a look. The rash was gone.

Concerning her case, I had little to discuss clinically with my student. He already knew that not every groin rash is fungal, but he also knew that in the greater world the default diagnosis is that every rash is probably a fungus, even if the cream often prescribed is anti-yeast. What interested me was this patient's attitude toward her experience, marked by gratitude, even wonder, rather than the irritation and resentment she might have expressed.

She could have said: “How come my primary doctor didn't know what this was and thought I needed surgery? Why did the surgeon think it was a fungus, and when I said the fungus cream wasn't working, why did he tell me to use even more of it? Why did it take my husband to get it right?"

But she did not say any of these things, she didn't even think them. Even when she referred to the time and "hundreds of dollars" the doctor's visits and creams took, there was nothing in her tone to suggest she was biting her tongue. She was just delighted that everything had worked out.

We often complain that patients don't cut us enough slack. If things didn't work out as well as they wished, as fast as they expected, or if we kept them waiting longer than they wanted – whether or not any of this was within our control – they let us know loud and clear that we haven't measured up.

Letting off steam from time to time about patients and frustrations is fair enough, but it’s worth reflecting on how many patients cut us plenty of slack, perhaps more than they should. I’m sometimes bemused, for instance, when I see a new acne patient who has just moved to the area. I ask him what he's been treated with.

"Minocycline."

"How long?"

"Three years."

"Is it working?"

"No."

"So what did the doctor say when you came back to see him?"

"Keep taking the minocycline."

Considering the people who call us every 3 days to complain that their pimples aren't going away, how do we explain why this gentleman (or his mother) didn't ask, "Say, doc, haven't you got anything else?"

Challenging an authority figure is not easy for most people. Many are reluctant to do so, if for no other reason than if they don't trust the person they're asking advice from, where exactly does that leave them?

And so many patients have so much trust and confidence in us that they overlook – or don't notice – if we fail to get the diagnosis right the first (or second) time, if the medication we prescribed had a side effect we didn't tell them about, or if it cost them a bundle because their insurance covered less than we figured.

The truth is that most patients cut us plenty of slack. Sometimes more than we deserve

Let's face it: Procrustes was a lousy host. Sure he had a nice bed, solid iron, nothing like what you would find at Bob's Discount Furniture with matching night table and love seat. But his bed was just one size, and Procrustes did what it took to make every guest fit it, even if he had to stretch out short people or chop the legs off long ones.

Courtesy flickr user tomislaymedakt (Creative Commons)

When I put diagnostic codes on patient encounter forms, I often feel like I am channeling my inner Procrustes by shoe-horning unwitting people, whether they fit or not, into the categories I have available. All too often, there are no codes available to fit what my patients have, but I have to pick one anyway. I can't bill without a diagnostic code, and I do like to get paid.

Consider Jerry, a high-school wrestling coach with scabs up and down both forearms. For several weeks, Jerry's been going quietly crazy trying to get his arms cleared up, but with no success. One doctor tried treating him for bugs, which didn't help his itching but did make Jerry feel worse about his situation and prospects. He had taken weeks off from work for fear of sharing something contagious with the kids he coaches. He knows wrestlers pick up many nasty things from each other anyway.

"Every night when I try to fall asleep, I scratch myself silly," he said. "I can't stop. At this point, I don't think I'll ever get better."

The distribution of his forearm scabs was consistent with no disease I knew of. It did, however, fit with someone picking at oneself. So I gave Jerry an optimistic outlook, an itch pill to take at bedtime, a cream to apply twice a day, and the advice to cover both forearms with gauze and a bandage when he went to bed. I told him that would keep the cream on. It would, of course, also keep his fingers off.

My actual diagnosis was: "Wrestling-coach-who-knows-that-you-can-pick-up-bacteria-viruses-funguses-and-heaven-knows-what-else-from-those-dirty-mats-and-also-from-other-wrestlers-so-now-I've-got-one-of-them-and-I'll-never-get-better-and-I'll-have-to-quit-my-work."

But of course there is no diagnostic code for that. There is a code, however, for "neurotic excoriations," also called "dermatitis factitia, 698.4." Is Jerry really neurotic? Should he see a psychiatrist about his internal conflicts? As for "factitious," that means, "manmade, artificial, counterfeit." Jerry's scratches are indeed manmade, but are they counterfeit - is Jerry looking for workers' comp? No, actually he is "nervous-about-this-one-specific-thing-because-of-ideas-he-has-in-his-head-reinforced-by-what-he's-been-told." But there's no code for that.
So "dermatitis factitia, 698.4" it is. Procrustes would be proud.

Or consider Fred. He presented with some scratched areas on his fingers and hands that also did not fit a recognizable pattern. It turns out that Fred is a truck driver who, though still employed, now finds himself, after a recent divorce, living in a shelter for homeless men.

Fred's actual diagnosis: "I-am-a-clean-upstanding-gainfully-employed-man-forced-to-live-with- unwashed-people-and-who-knows-what-they-bring-back-to-the-room-from-wherever-they-go-all-day."

I know you'll be shocked to learn there's no code for that either. So I gave him an antibiotic ointment to put on (mostly to give him something to do besides scratch) and diagnostically went with "impetigo, 683."

Every diagnosis, regardless of how "organic," is full of meaning for each individual patient: Am I falling apart? Is this the beginning of the end? Am I following my family's pattern straight to health perdition? Am I so disgusting that I'll need to withdraw from polite society? There is, of course, no room on the encounter sheet for all this meaning stuff, only for "the diagnosis."

When it comes to people like Jerry and Fred, there really is no diagnosis, just meaning. Strip that away and everything gets better (which of course it did in both their cases). But the way things work in our medical motels, you've got to move 'em in and move 'em out, and nobody leaves without a code. If you don't code it, it didn't happen.

So codes they get. One size fits all. Let's hear it for Procrustes.

Let's face it: Procrustes was a lousy host. Sure he had a nice bed, solid iron, nothing like what you would find at Bob's Discount Furniture with matching night table and love seat. But his bed was just one size, and Procrustes did what it took to make every guest fit it, even if he had to stretch out short people or chop the legs off long ones.

Courtesy flickr user tomislaymedakt (Creative Commons)

When I put diagnostic codes on patient encounter forms, I often feel like I am channeling my inner Procrustes by shoe-horning unwitting people, whether they fit or not, into the categories I have available. All too often, there are no codes available to fit what my patients have, but I have to pick one anyway. I can't bill without a diagnostic code, and I do like to get paid.

Consider Jerry, a high-school wrestling coach with scabs up and down both forearms. For several weeks, Jerry's been going quietly crazy trying to get his arms cleared up, but with no success. One doctor tried treating him for bugs, which didn't help his itching but did make Jerry feel worse about his situation and prospects. He had taken weeks off from work for fear of sharing something contagious with the kids he coaches. He knows wrestlers pick up many nasty things from each other anyway.

"Every night when I try to fall asleep, I scratch myself silly," he said. "I can't stop. At this point, I don't think I'll ever get better."

The distribution of his forearm scabs was consistent with no disease I knew of. It did, however, fit with someone picking at oneself. So I gave Jerry an optimistic outlook, an itch pill to take at bedtime, a cream to apply twice a day, and the advice to cover both forearms with gauze and a bandage when he went to bed. I told him that would keep the cream on. It would, of course, also keep his fingers off.

My actual diagnosis was: "Wrestling-coach-who-knows-that-you-can-pick-up-bacteria-viruses-funguses-and-heaven-knows-what-else-from-those-dirty-mats-and-also-from-other-wrestlers-so-now-I've-got-one-of-them-and-I'll-never-get-better-and-I'll-have-to-quit-my-work."

But of course there is no diagnostic code for that. There is a code, however, for "neurotic excoriations," also called "dermatitis factitia, 698.4." Is Jerry really neurotic? Should he see a psychiatrist about his internal conflicts? As for "factitious," that means, "manmade, artificial, counterfeit." Jerry's scratches are indeed manmade, but are they counterfeit - is Jerry looking for workers' comp? No, actually he is "nervous-about-this-one-specific-thing-because-of-ideas-he-has-in-his-head-reinforced-by-what-he's-been-told." But there's no code for that.
So "dermatitis factitia, 698.4" it is. Procrustes would be proud.

Or consider Fred. He presented with some scratched areas on his fingers and hands that also did not fit a recognizable pattern. It turns out that Fred is a truck driver who, though still employed, now finds himself, after a recent divorce, living in a shelter for homeless men.

Fred's actual diagnosis: "I-am-a-clean-upstanding-gainfully-employed-man-forced-to-live-with- unwashed-people-and-who-knows-what-they-bring-back-to-the-room-from-wherever-they-go-all-day."

I know you'll be shocked to learn there's no code for that either. So I gave him an antibiotic ointment to put on (mostly to give him something to do besides scratch) and diagnostically went with "impetigo, 683."

Every diagnosis, regardless of how "organic," is full of meaning for each individual patient: Am I falling apart? Is this the beginning of the end? Am I following my family's pattern straight to health perdition? Am I so disgusting that I'll need to withdraw from polite society? There is, of course, no room on the encounter sheet for all this meaning stuff, only for "the diagnosis."

When it comes to people like Jerry and Fred, there really is no diagnosis, just meaning. Strip that away and everything gets better (which of course it did in both their cases). But the way things work in our medical motels, you've got to move 'em in and move 'em out, and nobody leaves without a code. If you don't code it, it didn't happen.

So codes they get. One size fits all. Let's hear it for Procrustes.

Let's face it: Procrustes was a lousy host. Sure he had a nice bed, solid iron, nothing like what you would find at Bob's Discount Furniture with matching night table and love seat. But his bed was just one size, and Procrustes did what it took to make every guest fit it, even if he had to stretch out short people or chop the legs off long ones.

Courtesy flickr user tomislaymedakt (Creative Commons)

When I put diagnostic codes on patient encounter forms, I often feel like I am channeling my inner Procrustes by shoe-horning unwitting people, whether they fit or not, into the categories I have available. All too often, there are no codes available to fit what my patients have, but I have to pick one anyway. I can't bill without a diagnostic code, and I do like to get paid.

Consider Jerry, a high-school wrestling coach with scabs up and down both forearms. For several weeks, Jerry's been going quietly crazy trying to get his arms cleared up, but with no success. One doctor tried treating him for bugs, which didn't help his itching but did make Jerry feel worse about his situation and prospects. He had taken weeks off from work for fear of sharing something contagious with the kids he coaches. He knows wrestlers pick up many nasty things from each other anyway.

"Every night when I try to fall asleep, I scratch myself silly," he said. "I can't stop. At this point, I don't think I'll ever get better."

The distribution of his forearm scabs was consistent with no disease I knew of. It did, however, fit with someone picking at oneself. So I gave Jerry an optimistic outlook, an itch pill to take at bedtime, a cream to apply twice a day, and the advice to cover both forearms with gauze and a bandage when he went to bed. I told him that would keep the cream on. It would, of course, also keep his fingers off.

My actual diagnosis was: "Wrestling-coach-who-knows-that-you-can-pick-up-bacteria-viruses-funguses-and-heaven-knows-what-else-from-those-dirty-mats-and-also-from-other-wrestlers-so-now-I've-got-one-of-them-and-I'll-never-get-better-and-I'll-have-to-quit-my-work."

But of course there is no diagnostic code for that. There is a code, however, for "neurotic excoriations," also called "dermatitis factitia, 698.4." Is Jerry really neurotic? Should he see a psychiatrist about his internal conflicts? As for "factitious," that means, "manmade, artificial, counterfeit." Jerry's scratches are indeed manmade, but are they counterfeit - is Jerry looking for workers' comp? No, actually he is "nervous-about-this-one-specific-thing-because-of-ideas-he-has-in-his-head-reinforced-by-what-he's-been-told." But there's no code for that.
So "dermatitis factitia, 698.4" it is. Procrustes would be proud.

Or consider Fred. He presented with some scratched areas on his fingers and hands that also did not fit a recognizable pattern. It turns out that Fred is a truck driver who, though still employed, now finds himself, after a recent divorce, living in a shelter for homeless men.

Fred's actual diagnosis: "I-am-a-clean-upstanding-gainfully-employed-man-forced-to-live-with- unwashed-people-and-who-knows-what-they-bring-back-to-the-room-from-wherever-they-go-all-day."

I know you'll be shocked to learn there's no code for that either. So I gave him an antibiotic ointment to put on (mostly to give him something to do besides scratch) and diagnostically went with "impetigo, 683."

Every diagnosis, regardless of how "organic," is full of meaning for each individual patient: Am I falling apart? Is this the beginning of the end? Am I following my family's pattern straight to health perdition? Am I so disgusting that I'll need to withdraw from polite society? There is, of course, no room on the encounter sheet for all this meaning stuff, only for "the diagnosis."

When it comes to people like Jerry and Fred, there really is no diagnosis, just meaning. Strip that away and everything gets better (which of course it did in both their cases). But the way things work in our medical motels, you've got to move 'em in and move 'em out, and nobody leaves without a code. If you don't code it, it didn't happen.

So codes they get. One size fits all. Let's hear it for Procrustes.

My gym's exercise equipment has warning labels pasted inches from the floor and printed in 8-point type. If you lie next to the machine and take off your glasses, you can make the words out. Nobody ever does that, but the manufacturer can always claim that they warned us if we're injured.

My electronic health record has a module for electronic prescription approvals. New pop-up warnings must now be addressed before an approval goes through. For instance, you can check, "benefit outweighs risks," or else, "advice from consultant." Since I'm the consultant, I often click this box to verify that I accept my own advice.

Here are some of the EHR warnings, followed by my grateful reactions:

• Clobetasol Propionate External Solution 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Warts are a more specific form of Viral Infection, the same precaution may apply.

Oh my gosh! You mean I shouldn’t use clobetasol in Systemic Viral Infection? I had no idea! And not even for warts?

• Clobetasol Propionate External Cream 0.05% should be used carefully in Viral Infection, especially in Systemic Viral Infection. Since Actinic Keratosis is a more specific form of Systemic Viral Infection, the same precaution may apply.

No clobetasol for viral Actinic Keratosis either? (By the way, what’s with the capitalization?)

• Clobetasol Propionate External Cream 0.05% should be used cautiously in Fungal Infection, especially in Systemic Fungal Infection. Since Dermatophytosis is a more specific form of Fungal Infection, the same precaution may apply.

You’re killing me! Well, at least clobetasol is okay for funguses if I use it cautiously.

• Efficacy of Minocycline HCL Oral capsule 100 MG against Helicobacter pylori is not impaired by food.

This is great news for my hungry acne patients with Helicobacter.

• Triamcinolone Acetionide External Cream 0.1% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Actinic Keratosis is a more specific form of Viral Infection, the same precaution may apply.

If I can’t use either clobetasol or triamcinolone, how am I supposed to treat Systemic Viral Infections like Actinic Keratosis?! Can I use the Internal Cream instead of the External one?

• Since Rubella-Like Rash is a more specific form of Viral Infection, the same precaution (re: using topical steroids) may apply.

May apply? You’re not sure? How Rubella-Like do they have to be? Extremely Rubella-Like? Moderately? How about Measles-Like? Coxsackie-like?

• The sedative effects of HydrOXYzine Oral Tablet 10 MG may be enhanced by quantities of alcohol contained in alcoholic beverages.

Alcohol in alcoholic beverages? Who knew?

• Betamethasone Dipropionate External Cream 0.05% should be used with extreme caution in Skin and Skin Structure Infection. Since Cellulitis is a more specific form of Skin and Skin Structure Infection, the same precaution may apply.

First you won't let me use steroids for Viral Infections. Now you won't let me use them for Bacterial Infections. What am I supposed to use steroids for?

• Betamethasone Dipropionate External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Condyloma Acuminatum is a more specific form of Viral Infection, the same precaution may apply.

That's it, I’m through! Go ahead and withhold steroids from Genital Warts and let's see how well you do!

• Tazorac External Gel 0.05% should be used with extreme caution in Eczema.

Okay, okay. Can I use it for acne or psoriasis, the conditions for which it's indicated?

• The combination of MetroNIDAZOLE External Lotion 0.75% and Ethanol may produce alcohol intolerance reactions. Topically applied metronidazole would not be expected to produce this reaction based on data indicating lack of absorption. Intravaginal metronidazole may be absorbed and could potentially lead to this reaction.

Now you've GONE ToO FAr. (I MEan wiTH the CAPitals.) Can't I just make sure that my rosacea patients don’t apply MetroNIDAZOLE intravaginally?

Honestly, who writes this stuff? More to the point, is the world a better place because they do?

A friend in environmental consulting said that in his line of work, bureaucratic form increasingly trumps substance, forcing people to spend time following quality regulations instead of actually improving quality.

Like gym equipment warnings, drug warnings are fine in theory. But what are they worth if their content is dubious if not laughable, and you don’t really need to read them, just click a box that says you did?

My gym's exercise equipment has warning labels pasted inches from the floor and printed in 8-point type. If you lie next to the machine and take off your glasses, you can make the words out. Nobody ever does that, but the manufacturer can always claim that they warned us if we're injured.

My electronic health record has a module for electronic prescription approvals. New pop-up warnings must now be addressed before an approval goes through. For instance, you can check, "benefit outweighs risks," or else, "advice from consultant." Since I'm the consultant, I often click this box to verify that I accept my own advice.

Here are some of the EHR warnings, followed by my grateful reactions:

• Clobetasol Propionate External Solution 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Warts are a more specific form of Viral Infection, the same precaution may apply.

Oh my gosh! You mean I shouldn’t use clobetasol in Systemic Viral Infection? I had no idea! And not even for warts?

• Clobetasol Propionate External Cream 0.05% should be used carefully in Viral Infection, especially in Systemic Viral Infection. Since Actinic Keratosis is a more specific form of Systemic Viral Infection, the same precaution may apply.

No clobetasol for viral Actinic Keratosis either? (By the way, what’s with the capitalization?)

• Clobetasol Propionate External Cream 0.05% should be used cautiously in Fungal Infection, especially in Systemic Fungal Infection. Since Dermatophytosis is a more specific form of Fungal Infection, the same precaution may apply.

You’re killing me! Well, at least clobetasol is okay for funguses if I use it cautiously.

• Efficacy of Minocycline HCL Oral capsule 100 MG against Helicobacter pylori is not impaired by food.

This is great news for my hungry acne patients with Helicobacter.

• Triamcinolone Acetionide External Cream 0.1% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Actinic Keratosis is a more specific form of Viral Infection, the same precaution may apply.

If I can’t use either clobetasol or triamcinolone, how am I supposed to treat Systemic Viral Infections like Actinic Keratosis?! Can I use the Internal Cream instead of the External one?

• Since Rubella-Like Rash is a more specific form of Viral Infection, the same precaution (re: using topical steroids) may apply.

May apply? You’re not sure? How Rubella-Like do they have to be? Extremely Rubella-Like? Moderately? How about Measles-Like? Coxsackie-like?

• The sedative effects of HydrOXYzine Oral Tablet 10 MG may be enhanced by quantities of alcohol contained in alcoholic beverages.

Alcohol in alcoholic beverages? Who knew?

• Betamethasone Dipropionate External Cream 0.05% should be used with extreme caution in Skin and Skin Structure Infection. Since Cellulitis is a more specific form of Skin and Skin Structure Infection, the same precaution may apply.

First you won't let me use steroids for Viral Infections. Now you won't let me use them for Bacterial Infections. What am I supposed to use steroids for?

• Betamethasone Dipropionate External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Condyloma Acuminatum is a more specific form of Viral Infection, the same precaution may apply.

That's it, I’m through! Go ahead and withhold steroids from Genital Warts and let's see how well you do!

• Tazorac External Gel 0.05% should be used with extreme caution in Eczema.

Okay, okay. Can I use it for acne or psoriasis, the conditions for which it's indicated?

• The combination of MetroNIDAZOLE External Lotion 0.75% and Ethanol may produce alcohol intolerance reactions. Topically applied metronidazole would not be expected to produce this reaction based on data indicating lack of absorption. Intravaginal metronidazole may be absorbed and could potentially lead to this reaction.

Now you've GONE ToO FAr. (I MEan wiTH the CAPitals.) Can't I just make sure that my rosacea patients don’t apply MetroNIDAZOLE intravaginally?

Honestly, who writes this stuff? More to the point, is the world a better place because they do?

A friend in environmental consulting said that in his line of work, bureaucratic form increasingly trumps substance, forcing people to spend time following quality regulations instead of actually improving quality.

Like gym equipment warnings, drug warnings are fine in theory. But what are they worth if their content is dubious if not laughable, and you don’t really need to read them, just click a box that says you did?

My gym's exercise equipment has warning labels pasted inches from the floor and printed in 8-point type. If you lie next to the machine and take off your glasses, you can make the words out. Nobody ever does that, but the manufacturer can always claim that they warned us if we're injured.

My electronic health record has a module for electronic prescription approvals. New pop-up warnings must now be addressed before an approval goes through. For instance, you can check, "benefit outweighs risks," or else, "advice from consultant." Since I'm the consultant, I often click this box to verify that I accept my own advice.

Here are some of the EHR warnings, followed by my grateful reactions:

• Clobetasol Propionate External Solution 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Warts are a more specific form of Viral Infection, the same precaution may apply.

Oh my gosh! You mean I shouldn’t use clobetasol in Systemic Viral Infection? I had no idea! And not even for warts?

• Clobetasol Propionate External Cream 0.05% should be used carefully in Viral Infection, especially in Systemic Viral Infection. Since Actinic Keratosis is a more specific form of Systemic Viral Infection, the same precaution may apply.

No clobetasol for viral Actinic Keratosis either? (By the way, what’s with the capitalization?)

• Clobetasol Propionate External Cream 0.05% should be used cautiously in Fungal Infection, especially in Systemic Fungal Infection. Since Dermatophytosis is a more specific form of Fungal Infection, the same precaution may apply.

You’re killing me! Well, at least clobetasol is okay for funguses if I use it cautiously.

• Efficacy of Minocycline HCL Oral capsule 100 MG against Helicobacter pylori is not impaired by food.

This is great news for my hungry acne patients with Helicobacter.

• Triamcinolone Acetionide External Cream 0.1% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Actinic Keratosis is a more specific form of Viral Infection, the same precaution may apply.

If I can’t use either clobetasol or triamcinolone, how am I supposed to treat Systemic Viral Infections like Actinic Keratosis?! Can I use the Internal Cream instead of the External one?

• Since Rubella-Like Rash is a more specific form of Viral Infection, the same precaution (re: using topical steroids) may apply.

May apply? You’re not sure? How Rubella-Like do they have to be? Extremely Rubella-Like? Moderately? How about Measles-Like? Coxsackie-like?

• The sedative effects of HydrOXYzine Oral Tablet 10 MG may be enhanced by quantities of alcohol contained in alcoholic beverages.

Alcohol in alcoholic beverages? Who knew?

• Betamethasone Dipropionate External Cream 0.05% should be used with extreme caution in Skin and Skin Structure Infection. Since Cellulitis is a more specific form of Skin and Skin Structure Infection, the same precaution may apply.

First you won't let me use steroids for Viral Infections. Now you won't let me use them for Bacterial Infections. What am I supposed to use steroids for?

• Betamethasone Dipropionate External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection. Since Condyloma Acuminatum is a more specific form of Viral Infection, the same precaution may apply.

That's it, I’m through! Go ahead and withhold steroids from Genital Warts and let's see how well you do!

• Tazorac External Gel 0.05% should be used with extreme caution in Eczema.

Okay, okay. Can I use it for acne or psoriasis, the conditions for which it's indicated?

• The combination of MetroNIDAZOLE External Lotion 0.75% and Ethanol may produce alcohol intolerance reactions. Topically applied metronidazole would not be expected to produce this reaction based on data indicating lack of absorption. Intravaginal metronidazole may be absorbed and could potentially lead to this reaction.

Now you've GONE ToO FAr. (I MEan wiTH the CAPitals.) Can't I just make sure that my rosacea patients don’t apply MetroNIDAZOLE intravaginally?

Honestly, who writes this stuff? More to the point, is the world a better place because they do?

A friend in environmental consulting said that in his line of work, bureaucratic form increasingly trumps substance, forcing people to spend time following quality regulations instead of actually improving quality.

Like gym equipment warnings, drug warnings are fine in theory. But what are they worth if their content is dubious if not laughable, and you don’t really need to read them, just click a box that says you did?

Good morning, Doctor. I haven’t seen you in a year, and I have so many questions to discuss. Here, I wrote them down, so I wouldn’t forget any. They’re all pretty minor, or at least I hope so.

Let’s see. This spot here on my left shin? You froze it last year, but it didn’t go away. There’s another one just like it on the other leg. They look the same, but I sometimes feel a pain under this one on the left, and the one on the right sometimes itches. Could that mean anything?

And here’s another spot near my right elbow. Right now it looks brown, but occasionally it looks red. I put cream on it, which seems to help sometimes but not always. I think it was the cream you gave me last year, but it could be the cream my primary doctor gave me a couple of years ago for a rash. I didn’t bring it with me, but it might be at home. It’s in a tube. I think it has a green stripe on it, or maybe yellow. If the red spot comes back, should I use the cream again?

Let me look at my list. Oh, yes, look right here, below my right armpit. You can see it if I twist this way – yes, there it is. Now, what’s really interesting is that my mother and sister have exactly the same mole. Isn’t that amazing? Do you think it should be removed? My sister had it removed, but my mother left hers alone. I take after my sister in a lot of ways, but I have my mother’s skin. My brother does, too, but not my other sister.

And here is something really interesting. You see this area here, on my side? There was a spot there. You can’t see it, but it was there 2 weeks ago, which is why I made the appointment. I was at a party at the house of a friend of a friend. I’ve been there once or twice, but I’m not that familiar with the layout. I like the hostess, but not her husband that much. Anyhow, I went into the kitchen to get something to drink. They just had the kitchen redone, and it looks like it cost them a fortune. Anyway, I bumped into the new island and hit that part of my body. It hurt for a while – I guess that would make sense, since I hit it – but when I looked for the spot the next day, I couldn’t find it. Isn’t that interesting? So I was wondering whether a spot could just fall off like that and whether hitting it could cause some sort of problem. I know I shouldn’t pick at things, but sometimes it’s an accident, and I can’t help it.

Okay, that should be about it. Let me see, did I already ask you about the one in my armpit? Yes, I think I did. So there are really only a couple of more areas I was concerned about. There’s this spot on my right ear. Yes, over there. And a dark area on my left ankle … no, not there, right there. Let me turn over the page – I have a few more questions. And I have a funny sensation near my navel, but only sometimes. I know, I can’t see anything either, but it bothers me when the weather changes.

I think that’s my whole list. Let’s see. Wait, did I ask you about the spot on my leg? Yes, I think I did. You’re sure the pain isn’t related to the spot? Okay, let me turn over the paper again. That may be it. … Let me just check, as long as I have you. Okay, let me see now. That should be about it. Let me just double-check. Yes, we talked about that, and that. And that. Right, that one. Okay, I guess we’re done. I appreciate your taking the time to answer all my questions. Yes, I hope you have a pleasant year, too. Take care, now. Oh, Doctor! Wait 1 second, I just thought of something, while I have you.

I think my hair is falling out.

Good morning, Doctor. I haven’t seen you in a year, and I have so many questions to discuss. Here, I wrote them down, so I wouldn’t forget any. They’re all pretty minor, or at least I hope so.

Let’s see. This spot here on my left shin? You froze it last year, but it didn’t go away. There’s another one just like it on the other leg. They look the same, but I sometimes feel a pain under this one on the left, and the one on the right sometimes itches. Could that mean anything?

And here’s another spot near my right elbow. Right now it looks brown, but occasionally it looks red. I put cream on it, which seems to help sometimes but not always. I think it was the cream you gave me last year, but it could be the cream my primary doctor gave me a couple of years ago for a rash. I didn’t bring it with me, but it might be at home. It’s in a tube. I think it has a green stripe on it, or maybe yellow. If the red spot comes back, should I use the cream again?

Let me look at my list. Oh, yes, look right here, below my right armpit. You can see it if I twist this way – yes, there it is. Now, what’s really interesting is that my mother and sister have exactly the same mole. Isn’t that amazing? Do you think it should be removed? My sister had it removed, but my mother left hers alone. I take after my sister in a lot of ways, but I have my mother’s skin. My brother does, too, but not my other sister.

And here is something really interesting. You see this area here, on my side? There was a spot there. You can’t see it, but it was there 2 weeks ago, which is why I made the appointment. I was at a party at the house of a friend of a friend. I’ve been there once or twice, but I’m not that familiar with the layout. I like the hostess, but not her husband that much. Anyhow, I went into the kitchen to get something to drink. They just had the kitchen redone, and it looks like it cost them a fortune. Anyway, I bumped into the new island and hit that part of my body. It hurt for a while – I guess that would make sense, since I hit it – but when I looked for the spot the next day, I couldn’t find it. Isn’t that interesting? So I was wondering whether a spot could just fall off like that and whether hitting it could cause some sort of problem. I know I shouldn’t pick at things, but sometimes it’s an accident, and I can’t help it.

Okay, that should be about it. Let me see, did I already ask you about the one in my armpit? Yes, I think I did. So there are really only a couple of more areas I was concerned about. There’s this spot on my right ear. Yes, over there. And a dark area on my left ankle … no, not there, right there. Let me turn over the page – I have a few more questions. And I have a funny sensation near my navel, but only sometimes. I know, I can’t see anything either, but it bothers me when the weather changes.

I think that’s my whole list. Let’s see. Wait, did I ask you about the spot on my leg? Yes, I think I did. You’re sure the pain isn’t related to the spot? Okay, let me turn over the paper again. That may be it. … Let me just check, as long as I have you. Okay, let me see now. That should be about it. Let me just double-check. Yes, we talked about that, and that. And that. Right, that one. Okay, I guess we’re done. I appreciate your taking the time to answer all my questions. Yes, I hope you have a pleasant year, too. Take care, now. Oh, Doctor! Wait 1 second, I just thought of something, while I have you.

I think my hair is falling out.

Good morning, Doctor. I haven’t seen you in a year, and I have so many questions to discuss. Here, I wrote them down, so I wouldn’t forget any. They’re all pretty minor, or at least I hope so.

Let’s see. This spot here on my left shin? You froze it last year, but it didn’t go away. There’s another one just like it on the other leg. They look the same, but I sometimes feel a pain under this one on the left, and the one on the right sometimes itches. Could that mean anything?

And here’s another spot near my right elbow. Right now it looks brown, but occasionally it looks red. I put cream on it, which seems to help sometimes but not always. I think it was the cream you gave me last year, but it could be the cream my primary doctor gave me a couple of years ago for a rash. I didn’t bring it with me, but it might be at home. It’s in a tube. I think it has a green stripe on it, or maybe yellow. If the red spot comes back, should I use the cream again?

Let me look at my list. Oh, yes, look right here, below my right armpit. You can see it if I twist this way – yes, there it is. Now, what’s really interesting is that my mother and sister have exactly the same mole. Isn’t that amazing? Do you think it should be removed? My sister had it removed, but my mother left hers alone. I take after my sister in a lot of ways, but I have my mother’s skin. My brother does, too, but not my other sister.

And here is something really interesting. You see this area here, on my side? There was a spot there. You can’t see it, but it was there 2 weeks ago, which is why I made the appointment. I was at a party at the house of a friend of a friend. I’ve been there once or twice, but I’m not that familiar with the layout. I like the hostess, but not her husband that much. Anyhow, I went into the kitchen to get something to drink. They just had the kitchen redone, and it looks like it cost them a fortune. Anyway, I bumped into the new island and hit that part of my body. It hurt for a while – I guess that would make sense, since I hit it – but when I looked for the spot the next day, I couldn’t find it. Isn’t that interesting? So I was wondering whether a spot could just fall off like that and whether hitting it could cause some sort of problem. I know I shouldn’t pick at things, but sometimes it’s an accident, and I can’t help it.

Okay, that should be about it. Let me see, did I already ask you about the one in my armpit? Yes, I think I did. So there are really only a couple of more areas I was concerned about. There’s this spot on my right ear. Yes, over there. And a dark area on my left ankle … no, not there, right there. Let me turn over the page – I have a few more questions. And I have a funny sensation near my navel, but only sometimes. I know, I can’t see anything either, but it bothers me when the weather changes.

I think that’s my whole list. Let’s see. Wait, did I ask you about the spot on my leg? Yes, I think I did. You’re sure the pain isn’t related to the spot? Okay, let me turn over the paper again. That may be it. … Let me just check, as long as I have you. Okay, let me see now. That should be about it. Let me just double-check. Yes, we talked about that, and that. And that. Right, that one. Okay, I guess we’re done. I appreciate your taking the time to answer all my questions. Yes, I hope you have a pleasant year, too. Take care, now. Oh, Doctor! Wait 1 second, I just thought of something, while I have you.

I think my hair is falling out.