Under My Skin

Rosalie hadn't been by in 3 years. Her chief concern was a growth on her forearm. Then she pointed to a cholesterol deposit above her right eye. “I thought it might have been from crying,” she said. “My daughter died 14 months ago. She was 26.”

I expressed sympathy, and asked if her daughter had been ill. “It's a long story,” she said, “but the short of it is that she had a boyfriend who was not a good person. He stored a gun in her closet, and she didn't even know it was there. One night she came home after going out drinking with her girlfriends, other nurses from the hospital. She tripped in the closet, and the gun went off.

“She used to be your patient,” Rosalie said. “Maybe you remember—she got those crazy warts when she was in middle school.” I checked my records. Her daughter's last visit was in 1996, when she was 13.

In our offices, as elsewhere in our lives, people pass across our line of vision and disappear. We may find out what becomes of them, medically or otherwise, but more often we don't. Sometimes a chance encounter brings their image back into focus, but for the most part, once out of sight they stay out of mind.

This is true not just of patients like Rosalie's daughter who come a time or two for a minor complaint, but for those we get to know over a sustained period. All at once you realize that you haven't seen them lately, and perhaps never will.

Terry is so familiar that I was surprised to see she hadn't come for over a year. Now past 80, she looked a bit frailer but still reasonably hale. I recalled that Tim, her husband and inseparable companion, hadn't come along for her last couple of visits. He wasn't up to it, she'd explained. His mind was getting a little fuzzy. He sent his regards.

This time I asked Terry about him with some hesitation. Dementia, after all, goes in just one direction. “He's doing fairly well,” she said. “Lately when Tim sees women on the TV, he thinks they can see him, so he won't undress in the bedroom because he's embarrassed. I tell him, 'Timmy, why aren't you worried that the men in the TV can see me?' But he still won't get into his pajamas until I turn off the TV.

“During the day he's pretty content,” she went on. “He just sits there by his radio, all day long. He loves to listen to it and look out the window. He can sit there for hours.”

Terry's report jogged my memory of the way Tim looked when I saw him last, an affable gent with a wiry build and thinning brown hair. He always had a smile on his face, ready to help me reassure his wife, the worrier of the pair. At the end of each visit I would wish them good health and say I was looking forward to seeing them next year. Now that I won't be seeing him anymore, I'll have to picture the Tim in Terry's description, listening to his murmuring radio and gazing out the window as he subsides into his own deepening twilight.

Of course, it's not only patients who are lost to follow-up. People come to the office and tell me they had a physical or biopsy as recently as 2 or 3 years ago but cannot for the life of them remember which doctor they saw. It's not even unusual for someone to come back to me after an absence of a decade or two and express disbelief that they'd ever been here, since neither the office nor its proprietor rang a bell.

When I was starting out in practice, an older colleague told me that once he announced his retirement, his mailbox filled and his phone rang off the hook with messages from anguished patients declaring that they simply would not be able to get along without him. “They did manage, though,” he said. “In most cases it took only a couple of weeks.”

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at sknews@elsevier.com

Rosalie hadn't been by in 3 years. Her chief concern was a growth on her forearm. Then she pointed to a cholesterol deposit above her right eye. “I thought it might have been from crying,” she said. “My daughter died 14 months ago. She was 26.”

I expressed sympathy, and asked if her daughter had been ill. “It's a long story,” she said, “but the short of it is that she had a boyfriend who was not a good person. He stored a gun in her closet, and she didn't even know it was there. One night she came home after going out drinking with her girlfriends, other nurses from the hospital. She tripped in the closet, and the gun went off.

“She used to be your patient,” Rosalie said. “Maybe you remember—she got those crazy warts when she was in middle school.” I checked my records. Her daughter's last visit was in 1996, when she was 13.

In our offices, as elsewhere in our lives, people pass across our line of vision and disappear. We may find out what becomes of them, medically or otherwise, but more often we don't. Sometimes a chance encounter brings their image back into focus, but for the most part, once out of sight they stay out of mind.

This is true not just of patients like Rosalie's daughter who come a time or two for a minor complaint, but for those we get to know over a sustained period. All at once you realize that you haven't seen them lately, and perhaps never will.

Terry is so familiar that I was surprised to see she hadn't come for over a year. Now past 80, she looked a bit frailer but still reasonably hale. I recalled that Tim, her husband and inseparable companion, hadn't come along for her last couple of visits. He wasn't up to it, she'd explained. His mind was getting a little fuzzy. He sent his regards.

This time I asked Terry about him with some hesitation. Dementia, after all, goes in just one direction. “He's doing fairly well,” she said. “Lately when Tim sees women on the TV, he thinks they can see him, so he won't undress in the bedroom because he's embarrassed. I tell him, 'Timmy, why aren't you worried that the men in the TV can see me?' But he still won't get into his pajamas until I turn off the TV.

“During the day he's pretty content,” she went on. “He just sits there by his radio, all day long. He loves to listen to it and look out the window. He can sit there for hours.”

Terry's report jogged my memory of the way Tim looked when I saw him last, an affable gent with a wiry build and thinning brown hair. He always had a smile on his face, ready to help me reassure his wife, the worrier of the pair. At the end of each visit I would wish them good health and say I was looking forward to seeing them next year. Now that I won't be seeing him anymore, I'll have to picture the Tim in Terry's description, listening to his murmuring radio and gazing out the window as he subsides into his own deepening twilight.

Of course, it's not only patients who are lost to follow-up. People come to the office and tell me they had a physical or biopsy as recently as 2 or 3 years ago but cannot for the life of them remember which doctor they saw. It's not even unusual for someone to come back to me after an absence of a decade or two and express disbelief that they'd ever been here, since neither the office nor its proprietor rang a bell.

When I was starting out in practice, an older colleague told me that once he announced his retirement, his mailbox filled and his phone rang off the hook with messages from anguished patients declaring that they simply would not be able to get along without him. “They did manage, though,” he said. “In most cases it took only a couple of weeks.”

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at sknews@elsevier.com

Rosalie hadn't been by in 3 years. Her chief concern was a growth on her forearm. Then she pointed to a cholesterol deposit above her right eye. “I thought it might have been from crying,” she said. “My daughter died 14 months ago. She was 26.”

I expressed sympathy, and asked if her daughter had been ill. “It's a long story,” she said, “but the short of it is that she had a boyfriend who was not a good person. He stored a gun in her closet, and she didn't even know it was there. One night she came home after going out drinking with her girlfriends, other nurses from the hospital. She tripped in the closet, and the gun went off.

“She used to be your patient,” Rosalie said. “Maybe you remember—she got those crazy warts when she was in middle school.” I checked my records. Her daughter's last visit was in 1996, when she was 13.

In our offices, as elsewhere in our lives, people pass across our line of vision and disappear. We may find out what becomes of them, medically or otherwise, but more often we don't. Sometimes a chance encounter brings their image back into focus, but for the most part, once out of sight they stay out of mind.

This is true not just of patients like Rosalie's daughter who come a time or two for a minor complaint, but for those we get to know over a sustained period. All at once you realize that you haven't seen them lately, and perhaps never will.

Terry is so familiar that I was surprised to see she hadn't come for over a year. Now past 80, she looked a bit frailer but still reasonably hale. I recalled that Tim, her husband and inseparable companion, hadn't come along for her last couple of visits. He wasn't up to it, she'd explained. His mind was getting a little fuzzy. He sent his regards.

This time I asked Terry about him with some hesitation. Dementia, after all, goes in just one direction. “He's doing fairly well,” she said. “Lately when Tim sees women on the TV, he thinks they can see him, so he won't undress in the bedroom because he's embarrassed. I tell him, 'Timmy, why aren't you worried that the men in the TV can see me?' But he still won't get into his pajamas until I turn off the TV.

“During the day he's pretty content,” she went on. “He just sits there by his radio, all day long. He loves to listen to it and look out the window. He can sit there for hours.”

Terry's report jogged my memory of the way Tim looked when I saw him last, an affable gent with a wiry build and thinning brown hair. He always had a smile on his face, ready to help me reassure his wife, the worrier of the pair. At the end of each visit I would wish them good health and say I was looking forward to seeing them next year. Now that I won't be seeing him anymore, I'll have to picture the Tim in Terry's description, listening to his murmuring radio and gazing out the window as he subsides into his own deepening twilight.

Of course, it's not only patients who are lost to follow-up. People come to the office and tell me they had a physical or biopsy as recently as 2 or 3 years ago but cannot for the life of them remember which doctor they saw. It's not even unusual for someone to come back to me after an absence of a decade or two and express disbelief that they'd ever been here, since neither the office nor its proprietor rang a bell.

When I was starting out in practice, an older colleague told me that once he announced his retirement, his mailbox filled and his phone rang off the hook with messages from anguished patients declaring that they simply would not be able to get along without him. “They did manage, though,” he said. “In most cases it took only a couple of weeks.”

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at sknews@elsevier.com

I'm old enough to remember the actor Robert Young in “Father Knows Best.” Because his later hit TV series “Marcus Welby, M.D.” aired when I was in medical school and residency, I never saw a single episode, but his image as the kindly general practitioner who knew everybody in town seeped into my consciousness.

I am not a GP in a small town but a specialist in a big, anonymous urban agglomeration, where you don't expect to meet people you know when you walk down the street. Patients come from all directions (well, not the east—they'd have to swim). Some live nearby; others come from towns and travel in circles at some distance. Still, after 30 years, these circles sometimes intersect in unexpected ways, producing intimations of small-town, Welby warmth that can frankly be rather nice.

There was the time, for instance, when I was writing up a note one evening at a rest home nursing station, when the night nurse, who didn't look at all familiar, said, “I brought my son Ted to see you when he had warts as a kid.”

“How old is Ted now?” I asked.

“Thirty-six,” she said. “He has two kids and lives in Chicago. He still remembers how you used to pour the liquid nitrogen on the floor.”

You never know what leaves an impression on kids, including your own.

Two recent incidents illustrate what can happen when you hang around long enough. Shortly before I left for a week off last spring, my associate was called for jury duty on a Monday, the first day I was to be away.

Having already rescheduled once, she had no choice but to go to the courthouse in downtown Boston. We decided not to cancel patients for Tuesday and beyond until she found out whether she would be impaneled on a jury or released the same day. When the judge asked if anyone would find it difficult to stay for a trial, she came forward and told him that because I was away, she was the only one available to see patients.

The judge looked at her forms and frowned. “Dermatology, eh?” he said. “Not many emergencies there.”

He seemed disinclined to let her off. Then he looked further and said: “Full disclosure. I'm one of Dr. Rockoff's patients. Have a good day.”

When I saw the good judge some weeks later, I expressed surprise that he was presiding in a Boston courthouse, since his usual bailiwick is about 50 miles southeast. It turns out that he just happened to be assigned to Boston that day. Good thing, too.

A similar incident happened a few weeks ago when I exited a highway a few miles from my office onto a street with three lanes of traffic. I stayed in the right lane, which was clear. Several hundred yards further on, I learned why it was so clear: A sign read, “Right Lane Must Turn Right.” The famously aggressive Boston drivers in the jammed lane to my left seemed unlikely to let me in, leaving me with the prospect of turning onto an unfamiliar street that headed nowhere, certainly not where I wanted to go.

I, therefore, ignored the sign and drove straight through—into a police trap. An officer motioned for me to pull over behind the line of perpetrators already apprehended. As he asked for my license and registration, I fumed. “Relax, sir,” he said, “You're just getting a warning.” He walked to his cruiser to examine my documents.

A few minutes later a different officer came over, smiling broadly. “I really need to make an appointment,” he said. “I'm late for my annual. Drive safe,” he said, handing me my papers.

The truth is, I didn't recognize him, but I'll be sure to do so the next time he comes in.

I'm not suggesting being pleasant or helpful for the purpose of getting off jury duty or avoiding tickets. There are better reasons for trying to be competent, and besides, the odds against a practical payoff are too long.

Still, it is nice when, after casting bread upon the waters for a decade or three, some of it unexpectedly—and pleasantly—comes back.

Move over, Marcus.

I'm old enough to remember the actor Robert Young in “Father Knows Best.” Because his later hit TV series “Marcus Welby, M.D.” aired when I was in medical school and residency, I never saw a single episode, but his image as the kindly general practitioner who knew everybody in town seeped into my consciousness.

I am not a GP in a small town but a specialist in a big, anonymous urban agglomeration, where you don't expect to meet people you know when you walk down the street. Patients come from all directions (well, not the east—they'd have to swim). Some live nearby; others come from towns and travel in circles at some distance. Still, after 30 years, these circles sometimes intersect in unexpected ways, producing intimations of small-town, Welby warmth that can frankly be rather nice.

There was the time, for instance, when I was writing up a note one evening at a rest home nursing station, when the night nurse, who didn't look at all familiar, said, “I brought my son Ted to see you when he had warts as a kid.”

“How old is Ted now?” I asked.

“Thirty-six,” she said. “He has two kids and lives in Chicago. He still remembers how you used to pour the liquid nitrogen on the floor.”

You never know what leaves an impression on kids, including your own.

Two recent incidents illustrate what can happen when you hang around long enough. Shortly before I left for a week off last spring, my associate was called for jury duty on a Monday, the first day I was to be away.

Having already rescheduled once, she had no choice but to go to the courthouse in downtown Boston. We decided not to cancel patients for Tuesday and beyond until she found out whether she would be impaneled on a jury or released the same day. When the judge asked if anyone would find it difficult to stay for a trial, she came forward and told him that because I was away, she was the only one available to see patients.

The judge looked at her forms and frowned. “Dermatology, eh?” he said. “Not many emergencies there.”

He seemed disinclined to let her off. Then he looked further and said: “Full disclosure. I'm one of Dr. Rockoff's patients. Have a good day.”

When I saw the good judge some weeks later, I expressed surprise that he was presiding in a Boston courthouse, since his usual bailiwick is about 50 miles southeast. It turns out that he just happened to be assigned to Boston that day. Good thing, too.

A similar incident happened a few weeks ago when I exited a highway a few miles from my office onto a street with three lanes of traffic. I stayed in the right lane, which was clear. Several hundred yards further on, I learned why it was so clear: A sign read, “Right Lane Must Turn Right.” The famously aggressive Boston drivers in the jammed lane to my left seemed unlikely to let me in, leaving me with the prospect of turning onto an unfamiliar street that headed nowhere, certainly not where I wanted to go.

I, therefore, ignored the sign and drove straight through—into a police trap. An officer motioned for me to pull over behind the line of perpetrators already apprehended. As he asked for my license and registration, I fumed. “Relax, sir,” he said, “You're just getting a warning.” He walked to his cruiser to examine my documents.

A few minutes later a different officer came over, smiling broadly. “I really need to make an appointment,” he said. “I'm late for my annual. Drive safe,” he said, handing me my papers.

The truth is, I didn't recognize him, but I'll be sure to do so the next time he comes in.

I'm not suggesting being pleasant or helpful for the purpose of getting off jury duty or avoiding tickets. There are better reasons for trying to be competent, and besides, the odds against a practical payoff are too long.

Still, it is nice when, after casting bread upon the waters for a decade or three, some of it unexpectedly—and pleasantly—comes back.

Move over, Marcus.

I'm old enough to remember the actor Robert Young in “Father Knows Best.” Because his later hit TV series “Marcus Welby, M.D.” aired when I was in medical school and residency, I never saw a single episode, but his image as the kindly general practitioner who knew everybody in town seeped into my consciousness.

I am not a GP in a small town but a specialist in a big, anonymous urban agglomeration, where you don't expect to meet people you know when you walk down the street. Patients come from all directions (well, not the east—they'd have to swim). Some live nearby; others come from towns and travel in circles at some distance. Still, after 30 years, these circles sometimes intersect in unexpected ways, producing intimations of small-town, Welby warmth that can frankly be rather nice.

There was the time, for instance, when I was writing up a note one evening at a rest home nursing station, when the night nurse, who didn't look at all familiar, said, “I brought my son Ted to see you when he had warts as a kid.”

“How old is Ted now?” I asked.

“Thirty-six,” she said. “He has two kids and lives in Chicago. He still remembers how you used to pour the liquid nitrogen on the floor.”

You never know what leaves an impression on kids, including your own.

Two recent incidents illustrate what can happen when you hang around long enough. Shortly before I left for a week off last spring, my associate was called for jury duty on a Monday, the first day I was to be away.

Having already rescheduled once, she had no choice but to go to the courthouse in downtown Boston. We decided not to cancel patients for Tuesday and beyond until she found out whether she would be impaneled on a jury or released the same day. When the judge asked if anyone would find it difficult to stay for a trial, she came forward and told him that because I was away, she was the only one available to see patients.

The judge looked at her forms and frowned. “Dermatology, eh?” he said. “Not many emergencies there.”

He seemed disinclined to let her off. Then he looked further and said: “Full disclosure. I'm one of Dr. Rockoff's patients. Have a good day.”

When I saw the good judge some weeks later, I expressed surprise that he was presiding in a Boston courthouse, since his usual bailiwick is about 50 miles southeast. It turns out that he just happened to be assigned to Boston that day. Good thing, too.

A similar incident happened a few weeks ago when I exited a highway a few miles from my office onto a street with three lanes of traffic. I stayed in the right lane, which was clear. Several hundred yards further on, I learned why it was so clear: A sign read, “Right Lane Must Turn Right.” The famously aggressive Boston drivers in the jammed lane to my left seemed unlikely to let me in, leaving me with the prospect of turning onto an unfamiliar street that headed nowhere, certainly not where I wanted to go.

I, therefore, ignored the sign and drove straight through—into a police trap. An officer motioned for me to pull over behind the line of perpetrators already apprehended. As he asked for my license and registration, I fumed. “Relax, sir,” he said, “You're just getting a warning.” He walked to his cruiser to examine my documents.

A few minutes later a different officer came over, smiling broadly. “I really need to make an appointment,” he said. “I'm late for my annual. Drive safe,” he said, handing me my papers.

The truth is, I didn't recognize him, but I'll be sure to do so the next time he comes in.

I'm not suggesting being pleasant or helpful for the purpose of getting off jury duty or avoiding tickets. There are better reasons for trying to be competent, and besides, the odds against a practical payoff are too long.

Still, it is nice when, after casting bread upon the waters for a decade or three, some of it unexpectedly—and pleasantly—comes back.

Move over, Marcus.

There was a comic when I was a kid called “The Strange World of Mr. Mum.” Each strip featured an impassive gent in a small fedora who looked on, mum, at the odd things that always seemed to be going on as he passed by, like two masked crooks robbing each other at the same time.

Now and then things happen in my office that make me feel like Mr. Mum. I share them here without comment.

Tim, a 30ish architect with sandy hair, had petechiae around his eyes. I asked him whether he had been coughing very hard or straining at stool. Negative.

I mentally ran through other possibilities. Let's see, too old to be a baby born with a cord around his neck. … Tim broke into my reverie.

“Doctor, could walking on my hands across the office have anything to do with this?”

“Well, yes, Tim. Would I be out of line to ask why you walk across your office on your hands?”

“Oh, I just do it sometimes.”

Lynn flashed me a conspiratorial look. “Could your student leave the room?”

“Of course.” I shooed the kid out, wondering what private matter she had to discuss.

“I'm thinking of getting plastic surgery,” she said. “Tell me, who did your face?”

“What?!”

“No, really, just between us, I won't tell anybody. Who did your face?”

I managed to regain enough composure to say that I guessed I was flattered, but nobody did my face. She looked skeptical.

I didn't share this interchange with my student, who wouldn't have believed it anyway.

At a local medical conference, the guest speaker was giving us a heads-up on ICD-10. “It's going to be a lot more detailed than ICD-9,” she explained, adding that ICD-10 is slated to become mandatory in October 2013. (I heard some murmurs that October 2013 might be a good date to retire.)

The speaker flashed several examples of new ICD-10 codes on the screen. “For instance,” she said, “this is the code for a benign lesion of the left eyelid. And this [next slide] is the code for a benign lesion of the right eyelid.”

A doctor raised his hand. “What difference does it make which lid it's on?” he asked.

Some people just don't get it.

My heart sank when I entered the exam room and saw a young woman with grotesquely enlarged, hollowed-out earlobes that literally hung to her shoulders. What could she possibly want me to do with them?

Sue was quite pleasant. “See, this is how I make them bigger,” she said. “I make a cut at the top, and then put in a larger and larger coin to make the hole bigger until the skin heals around it. Now the earlobes are as big as I want them.” Well, yes.

“But here's my problem.” Sue pointed to a slight protrusion of tissue at the cavity's upper pole, at 12 o'clock. In other words, her problem was not the huge hole—the hole is what she wanted—but the scar at the top that impinged on the cavity and marred its perfection.

“In that case,” I said, “I can help you. I'll inject some cortisone into the bump and flatten it.”

“Fantastic!” she exclaimed. I gave her the shot and asked what her career plans were.

“Social work,” she explained.

Bob, in for a skin check, had a healing scab on his forehead. “Looks like you ran into a pipe and didn't duck fast enough,” I suggested.

“Not exactly,” said Bob. “I was making squid and shrimp pasta in the microwave. When all the pieces got nice and plump, I decided to test whether they were done, so I stuck a fork into one of the squid, and it exploded. Guess I was lucky it didn't get my eye.”

Microwave-induced exploding cats are said to be urban legends, but now you know, gentle readers, that exploding squid have been sighted. So don't forget to ask about them when you take your histories, as well as about whether your patients walk on their hands across their offices (or stand on their heads doing yoga).

I'll take my fedora off, for now.

There was a comic when I was a kid called “The Strange World of Mr. Mum.” Each strip featured an impassive gent in a small fedora who looked on, mum, at the odd things that always seemed to be going on as he passed by, like two masked crooks robbing each other at the same time.

Now and then things happen in my office that make me feel like Mr. Mum. I share them here without comment.

Tim, a 30ish architect with sandy hair, had petechiae around his eyes. I asked him whether he had been coughing very hard or straining at stool. Negative.

I mentally ran through other possibilities. Let's see, too old to be a baby born with a cord around his neck. … Tim broke into my reverie.

“Doctor, could walking on my hands across the office have anything to do with this?”

“Well, yes, Tim. Would I be out of line to ask why you walk across your office on your hands?”

“Oh, I just do it sometimes.”

Lynn flashed me a conspiratorial look. “Could your student leave the room?”

“Of course.” I shooed the kid out, wondering what private matter she had to discuss.

“I'm thinking of getting plastic surgery,” she said. “Tell me, who did your face?”

“What?!”

“No, really, just between us, I won't tell anybody. Who did your face?”

I managed to regain enough composure to say that I guessed I was flattered, but nobody did my face. She looked skeptical.

I didn't share this interchange with my student, who wouldn't have believed it anyway.

At a local medical conference, the guest speaker was giving us a heads-up on ICD-10. “It's going to be a lot more detailed than ICD-9,” she explained, adding that ICD-10 is slated to become mandatory in October 2013. (I heard some murmurs that October 2013 might be a good date to retire.)

The speaker flashed several examples of new ICD-10 codes on the screen. “For instance,” she said, “this is the code for a benign lesion of the left eyelid. And this [next slide] is the code for a benign lesion of the right eyelid.”

A doctor raised his hand. “What difference does it make which lid it's on?” he asked.

Some people just don't get it.

My heart sank when I entered the exam room and saw a young woman with grotesquely enlarged, hollowed-out earlobes that literally hung to her shoulders. What could she possibly want me to do with them?

Sue was quite pleasant. “See, this is how I make them bigger,” she said. “I make a cut at the top, and then put in a larger and larger coin to make the hole bigger until the skin heals around it. Now the earlobes are as big as I want them.” Well, yes.

“But here's my problem.” Sue pointed to a slight protrusion of tissue at the cavity's upper pole, at 12 o'clock. In other words, her problem was not the huge hole—the hole is what she wanted—but the scar at the top that impinged on the cavity and marred its perfection.

“In that case,” I said, “I can help you. I'll inject some cortisone into the bump and flatten it.”

“Fantastic!” she exclaimed. I gave her the shot and asked what her career plans were.

“Social work,” she explained.

Bob, in for a skin check, had a healing scab on his forehead. “Looks like you ran into a pipe and didn't duck fast enough,” I suggested.

“Not exactly,” said Bob. “I was making squid and shrimp pasta in the microwave. When all the pieces got nice and plump, I decided to test whether they were done, so I stuck a fork into one of the squid, and it exploded. Guess I was lucky it didn't get my eye.”

Microwave-induced exploding cats are said to be urban legends, but now you know, gentle readers, that exploding squid have been sighted. So don't forget to ask about them when you take your histories, as well as about whether your patients walk on their hands across their offices (or stand on their heads doing yoga).

I'll take my fedora off, for now.

There was a comic when I was a kid called “The Strange World of Mr. Mum.” Each strip featured an impassive gent in a small fedora who looked on, mum, at the odd things that always seemed to be going on as he passed by, like two masked crooks robbing each other at the same time.

Now and then things happen in my office that make me feel like Mr. Mum. I share them here without comment.

Tim, a 30ish architect with sandy hair, had petechiae around his eyes. I asked him whether he had been coughing very hard or straining at stool. Negative.

I mentally ran through other possibilities. Let's see, too old to be a baby born with a cord around his neck. … Tim broke into my reverie.

“Doctor, could walking on my hands across the office have anything to do with this?”

“Well, yes, Tim. Would I be out of line to ask why you walk across your office on your hands?”

“Oh, I just do it sometimes.”

Lynn flashed me a conspiratorial look. “Could your student leave the room?”

“Of course.” I shooed the kid out, wondering what private matter she had to discuss.

“I'm thinking of getting plastic surgery,” she said. “Tell me, who did your face?”

“What?!”

“No, really, just between us, I won't tell anybody. Who did your face?”

I managed to regain enough composure to say that I guessed I was flattered, but nobody did my face. She looked skeptical.

I didn't share this interchange with my student, who wouldn't have believed it anyway.

At a local medical conference, the guest speaker was giving us a heads-up on ICD-10. “It's going to be a lot more detailed than ICD-9,” she explained, adding that ICD-10 is slated to become mandatory in October 2013. (I heard some murmurs that October 2013 might be a good date to retire.)

The speaker flashed several examples of new ICD-10 codes on the screen. “For instance,” she said, “this is the code for a benign lesion of the left eyelid. And this [next slide] is the code for a benign lesion of the right eyelid.”

A doctor raised his hand. “What difference does it make which lid it's on?” he asked.

Some people just don't get it.

My heart sank when I entered the exam room and saw a young woman with grotesquely enlarged, hollowed-out earlobes that literally hung to her shoulders. What could she possibly want me to do with them?

Sue was quite pleasant. “See, this is how I make them bigger,” she said. “I make a cut at the top, and then put in a larger and larger coin to make the hole bigger until the skin heals around it. Now the earlobes are as big as I want them.” Well, yes.

“But here's my problem.” Sue pointed to a slight protrusion of tissue at the cavity's upper pole, at 12 o'clock. In other words, her problem was not the huge hole—the hole is what she wanted—but the scar at the top that impinged on the cavity and marred its perfection.

“In that case,” I said, “I can help you. I'll inject some cortisone into the bump and flatten it.”

“Fantastic!” she exclaimed. I gave her the shot and asked what her career plans were.

“Social work,” she explained.

Bob, in for a skin check, had a healing scab on his forehead. “Looks like you ran into a pipe and didn't duck fast enough,” I suggested.

“Not exactly,” said Bob. “I was making squid and shrimp pasta in the microwave. When all the pieces got nice and plump, I decided to test whether they were done, so I stuck a fork into one of the squid, and it exploded. Guess I was lucky it didn't get my eye.”

Microwave-induced exploding cats are said to be urban legends, but now you know, gentle readers, that exploding squid have been sighted. So don't forget to ask about them when you take your histories, as well as about whether your patients walk on their hands across their offices (or stand on their heads doing yoga).

I'll take my fedora off, for now.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these measures to rank doctors: the higher the tier, the lower the copay for patients. Earlier this year I got my report card.

I am Tier 1. Hear me roar.

Flushed with pride, I wrote the commission and insurers:

Dear Sirs:

Thank you for sending me my tier information. While I appreciate your endorsement and confidence, I hope you can help me understand your evaluation more fully so I can become an even better and more efficient doctor.

▸ Under Quality Measures, you reported that I had three "Opportunities in Your Practice" to avoid inappropriate use of Lotrisone (betamethasone and clotrimazole), and that I overcame temptation in each. I never use this combination steroid-antifungal preparation, however, choosing instead either a steroid or antifungal cream alone. Every scaly rash is an opportunity for using Lotrisone, and I treat hundreds of scaly rashes every year, yet you identify only three such opportunities. How did you choose them?

▸ Under Efficiency Performance, your first category is "viral skin infection." This could include warts, herpes simplex, herpes zoster, molluscum contagiosum, and viral exanthems. Warts take several visits; mollusca, one or two; herpes simplex, zoster, and exanthems, usually one. Is lumping all these into one category and giving a "cost per episode" a useful way to measure and guide clinical practice?

▸ You reported I had one case of "environmental trauma" with an episode cost of $2,335.47 (compared with a peer cost of $395.28). Could you please tell me what this refers to? A bolt of lightning? A falling tree? A really big spider?

▸ You refer to a category, "fungal skin infection without surg." Is there a fungal skin infection with surg? In the meantime, you reported for this nonsurgical category my surgical costs were $42.

▸ Under "All ETG's," you show a cost of $82 for "inpatient ancillary," but I haven't hospitalized a patient in almost 30 years.

▸ Category 4 within Efficiency Performance is "inflammation of the noncranial nerves, except carpal tunnel, w/o surgery." You reported I had one episode, with a cost of $2,155.64. Since I am not a neurologist, I'm not sure what this refers to. I could not have charged $2,155.64 for herpes zoster, since I never see shingles patients more than once or twice (and always w/o surgery.)

▸ Category 5 is "other minor orthopedic disorder." I am not an orthopedist.

In 4 months, I've received no answer. The man in charge of the state insurance commission hasn't answered either—I wrote him twice—even though he's my patient. Because our medical society is suing the state for using flawed data, perhaps his nonresponse is on advice of counsel.

It is, of course, easier to mock efforts to solve difficulties than to fix them, and the problems our health care system faces are severe. Fixing these problems, although essential, will be hard and costly. I can't help being skeptical, though, when I read that better outcomes data and performance measures can be counted on to improve care and save money. Will patients really choose doctors with higher rankings and lower copays? Do we really know how to figure out which neurosurgeon or dermatologist is superior?

It's hard for me to be confident that better measurement is the answer, when the model in my neighborhood has reportedly sanctioned doctors for giving care to patients they never saw. The quality measurement I know about takes sensible criteria (nonuse of Lotrisone) and applies them in incomprehensible ways; deals in unintelligible and self-contradictory categories (fungal infection w/o surgery, but with surgical fees); lumps the incommensurate; cannot figure out how to categorize data in a way that makes sure a dermatologist is not an orthopedist; and is administered by remote bureaucracies that respond, if at all, only to lawsuits.

This, of course, is just the worm's eye view of one doctor. May I remind you, however, that I am Tier 1.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these measures to rank doctors: the higher the tier, the lower the copay for patients. Earlier this year I got my report card.

I am Tier 1. Hear me roar.

Flushed with pride, I wrote the commission and insurers:

Dear Sirs:

Thank you for sending me my tier information. While I appreciate your endorsement and confidence, I hope you can help me understand your evaluation more fully so I can become an even better and more efficient doctor.

▸ Under Quality Measures, you reported that I had three "Opportunities in Your Practice" to avoid inappropriate use of Lotrisone (betamethasone and clotrimazole), and that I overcame temptation in each. I never use this combination steroid-antifungal preparation, however, choosing instead either a steroid or antifungal cream alone. Every scaly rash is an opportunity for using Lotrisone, and I treat hundreds of scaly rashes every year, yet you identify only three such opportunities. How did you choose them?

▸ Under Efficiency Performance, your first category is "viral skin infection." This could include warts, herpes simplex, herpes zoster, molluscum contagiosum, and viral exanthems. Warts take several visits; mollusca, one or two; herpes simplex, zoster, and exanthems, usually one. Is lumping all these into one category and giving a "cost per episode" a useful way to measure and guide clinical practice?

▸ You reported I had one case of "environmental trauma" with an episode cost of $2,335.47 (compared with a peer cost of $395.28). Could you please tell me what this refers to? A bolt of lightning? A falling tree? A really big spider?

▸ You refer to a category, "fungal skin infection without surg." Is there a fungal skin infection with surg? In the meantime, you reported for this nonsurgical category my surgical costs were $42.

▸ Under "All ETG's," you show a cost of $82 for "inpatient ancillary," but I haven't hospitalized a patient in almost 30 years.

▸ Category 4 within Efficiency Performance is "inflammation of the noncranial nerves, except carpal tunnel, w/o surgery." You reported I had one episode, with a cost of $2,155.64. Since I am not a neurologist, I'm not sure what this refers to. I could not have charged $2,155.64 for herpes zoster, since I never see shingles patients more than once or twice (and always w/o surgery.)

▸ Category 5 is "other minor orthopedic disorder." I am not an orthopedist.

In 4 months, I've received no answer. The man in charge of the state insurance commission hasn't answered either—I wrote him twice—even though he's my patient. Because our medical society is suing the state for using flawed data, perhaps his nonresponse is on advice of counsel.

It is, of course, easier to mock efforts to solve difficulties than to fix them, and the problems our health care system faces are severe. Fixing these problems, although essential, will be hard and costly. I can't help being skeptical, though, when I read that better outcomes data and performance measures can be counted on to improve care and save money. Will patients really choose doctors with higher rankings and lower copays? Do we really know how to figure out which neurosurgeon or dermatologist is superior?

It's hard for me to be confident that better measurement is the answer, when the model in my neighborhood has reportedly sanctioned doctors for giving care to patients they never saw. The quality measurement I know about takes sensible criteria (nonuse of Lotrisone) and applies them in incomprehensible ways; deals in unintelligible and self-contradictory categories (fungal infection w/o surgery, but with surgical fees); lumps the incommensurate; cannot figure out how to categorize data in a way that makes sure a dermatologist is not an orthopedist; and is administered by remote bureaucracies that respond, if at all, only to lawsuits.

This, of course, is just the worm's eye view of one doctor. May I remind you, however, that I am Tier 1.

The Massachusetts insurance commission has developed data to rate physicians by efficiency and quality. Two local insurers use these measures to rank doctors: the higher the tier, the lower the copay for patients. Earlier this year I got my report card.

I am Tier 1. Hear me roar.

Flushed with pride, I wrote the commission and insurers:

Dear Sirs:

Thank you for sending me my tier information. While I appreciate your endorsement and confidence, I hope you can help me understand your evaluation more fully so I can become an even better and more efficient doctor.

▸ Under Quality Measures, you reported that I had three "Opportunities in Your Practice" to avoid inappropriate use of Lotrisone (betamethasone and clotrimazole), and that I overcame temptation in each. I never use this combination steroid-antifungal preparation, however, choosing instead either a steroid or antifungal cream alone. Every scaly rash is an opportunity for using Lotrisone, and I treat hundreds of scaly rashes every year, yet you identify only three such opportunities. How did you choose them?

▸ Under Efficiency Performance, your first category is "viral skin infection." This could include warts, herpes simplex, herpes zoster, molluscum contagiosum, and viral exanthems. Warts take several visits; mollusca, one or two; herpes simplex, zoster, and exanthems, usually one. Is lumping all these into one category and giving a "cost per episode" a useful way to measure and guide clinical practice?

▸ You reported I had one case of "environmental trauma" with an episode cost of $2,335.47 (compared with a peer cost of $395.28). Could you please tell me what this refers to? A bolt of lightning? A falling tree? A really big spider?

▸ You refer to a category, "fungal skin infection without surg." Is there a fungal skin infection with surg? In the meantime, you reported for this nonsurgical category my surgical costs were $42.

▸ Under "All ETG's," you show a cost of $82 for "inpatient ancillary," but I haven't hospitalized a patient in almost 30 years.

▸ Category 4 within Efficiency Performance is "inflammation of the noncranial nerves, except carpal tunnel, w/o surgery." You reported I had one episode, with a cost of $2,155.64. Since I am not a neurologist, I'm not sure what this refers to. I could not have charged $2,155.64 for herpes zoster, since I never see shingles patients more than once or twice (and always w/o surgery.)

▸ Category 5 is "other minor orthopedic disorder." I am not an orthopedist.

In 4 months, I've received no answer. The man in charge of the state insurance commission hasn't answered either—I wrote him twice—even though he's my patient. Because our medical society is suing the state for using flawed data, perhaps his nonresponse is on advice of counsel.

It is, of course, easier to mock efforts to solve difficulties than to fix them, and the problems our health care system faces are severe. Fixing these problems, although essential, will be hard and costly. I can't help being skeptical, though, when I read that better outcomes data and performance measures can be counted on to improve care and save money. Will patients really choose doctors with higher rankings and lower copays? Do we really know how to figure out which neurosurgeon or dermatologist is superior?

It's hard for me to be confident that better measurement is the answer, when the model in my neighborhood has reportedly sanctioned doctors for giving care to patients they never saw. The quality measurement I know about takes sensible criteria (nonuse of Lotrisone) and applies them in incomprehensible ways; deals in unintelligible and self-contradictory categories (fungal infection w/o surgery, but with surgical fees); lumps the incommensurate; cannot figure out how to categorize data in a way that makes sure a dermatologist is not an orthopedist; and is administered by remote bureaucracies that respond, if at all, only to lawsuits.

This, of course, is just the worm's eye view of one doctor. May I remind you, however, that I am Tier 1.

I'm not sure why I agreed to speak at the mall, and gratis at that. Maybe it was nostalgia for the talks to community groups, primary care doctors, and television interviewers (at small, public-access stations) that I used to give when I was starting out. Or maybe it is because I just like to talk.

When I got to the local mall at 9:45 a.m., my hopes for a good crowd rose when I saw lines of people stretching out into the lobby. That lasted until I realized they were there for the Registry of Motor Vehicles.

My talk would be next door at the buffet restaurant. Posters announced this month's installment of the Health Awareness series, “Advances in Skin Cancer.” I met Janice, a twenty-something in charge of marketing for the strip mall. She led me inside the still-closed restaurant.

“Usually, they're done vacuuming before the lectures start,” she said. “You'll be speaking from here.” She pointed to a wood busing station against the near wall. I turned to face long, neat rows of small tables, each set with salt, pepper, ketchup, and steak sauce.

“How did you get my name?” I asked Janice.

“Google,” she replied. “Would you believe we called 30 dermatologists before we found you? The others were too busy or not interested.”

That was gratifying. “Do you get the same people coming to the lectures every month?”

“Pretty much,” she said as she indicated a list of regulars. “They check off their name so we can send them announcements.”

By then people started showing up. They all seemed to know Janice and each other. “These are good seats,” said one woman to her companion, taking a table in front.

Others shuffled in. By just after 10 a.m., 15 people had signed in and sat down. All were old and wan.

One woman sported a bulky gauze dressing on her left cheek. “My dermatologist took off a skin cancer this week,” she said, heading to her table.

“What kind of cancer was it?” I asked.

“I don't know,” she said. “I forgot to ask him.”

Janice offered no introduction. She distributed my one-page handout.

As instructed, I had brought no slides or PowerPoint presentations; the restaurant walls were unsuitable for either. My handout listed a number of Web sites on which to find pictures of skin cancer, though this crowd seemed unlikely to spend much time online.

I told them about basal and squamous cell carcinoma, melanoma, UVA and UVB, sunscreens, and vitamin D. I also mentioned tanning parlors, and we shared chuckles about the foolishness of kids.

One woman rose to testify. “I know my skin cancer came from a terrible sunburn on my chest,” she said. “My skin turned blue. Then I got this small, dark spot. One doctor said to forget about it, but I went to another one, and they did a test.”

I agreed that sunburns are undesirable, but suggested that a single bad one wouldn't necessarily generate cancer.

“What strength sunscreen do you recommend?” asked one woman.

“He already answered that,” said her table mate. “You have to pay attention!” I assumed this pair shared similar interchanges every month.

And so it went. The props were different from those in the old days: Instead of screens, slide projectors, or TV cameras, I now faced rows of inverted Heinz ketchup bottles. But the rest was familiar: the same facts, advice, questions, and even my jokes and their predictable responses. Everything about those talks came flooding back, including why I'd stopped giving them.

The public can't get enough medical news. What people really want to hear about are the breakthroughs and the exciting advances. Those of us who don't live on the clinical cutting edge have more mundane fare to offer, less like what comes from the lab bench or operating suite than what emanates from the pulpit.

Like pastors, we offer sage wisdom and sensible advice to people inclined to listen to us. They nod in agreement, and not much changes.

Also, like pastors, we don't give up. The same regulars come time after time, only maybe this time they'll pay closer attention so that our words hit home and nudge them a bit in the right direction.

So maybe that's why I agreed to speak. Or maybe I just like to talk.

I'm not sure why I agreed to speak at the mall, and gratis at that. Maybe it was nostalgia for the talks to community groups, primary care doctors, and television interviewers (at small, public-access stations) that I used to give when I was starting out. Or maybe it is because I just like to talk.

When I got to the local mall at 9:45 a.m., my hopes for a good crowd rose when I saw lines of people stretching out into the lobby. That lasted until I realized they were there for the Registry of Motor Vehicles.

My talk would be next door at the buffet restaurant. Posters announced this month's installment of the Health Awareness series, “Advances in Skin Cancer.” I met Janice, a twenty-something in charge of marketing for the strip mall. She led me inside the still-closed restaurant.

“Usually, they're done vacuuming before the lectures start,” she said. “You'll be speaking from here.” She pointed to a wood busing station against the near wall. I turned to face long, neat rows of small tables, each set with salt, pepper, ketchup, and steak sauce.

“How did you get my name?” I asked Janice.

“Google,” she replied. “Would you believe we called 30 dermatologists before we found you? The others were too busy or not interested.”

That was gratifying. “Do you get the same people coming to the lectures every month?”

“Pretty much,” she said as she indicated a list of regulars. “They check off their name so we can send them announcements.”

By then people started showing up. They all seemed to know Janice and each other. “These are good seats,” said one woman to her companion, taking a table in front.

Others shuffled in. By just after 10 a.m., 15 people had signed in and sat down. All were old and wan.

One woman sported a bulky gauze dressing on her left cheek. “My dermatologist took off a skin cancer this week,” she said, heading to her table.

“What kind of cancer was it?” I asked.

“I don't know,” she said. “I forgot to ask him.”

Janice offered no introduction. She distributed my one-page handout.

As instructed, I had brought no slides or PowerPoint presentations; the restaurant walls were unsuitable for either. My handout listed a number of Web sites on which to find pictures of skin cancer, though this crowd seemed unlikely to spend much time online.

I told them about basal and squamous cell carcinoma, melanoma, UVA and UVB, sunscreens, and vitamin D. I also mentioned tanning parlors, and we shared chuckles about the foolishness of kids.

One woman rose to testify. “I know my skin cancer came from a terrible sunburn on my chest,” she said. “My skin turned blue. Then I got this small, dark spot. One doctor said to forget about it, but I went to another one, and they did a test.”

I agreed that sunburns are undesirable, but suggested that a single bad one wouldn't necessarily generate cancer.

“What strength sunscreen do you recommend?” asked one woman.

“He already answered that,” said her table mate. “You have to pay attention!” I assumed this pair shared similar interchanges every month.

And so it went. The props were different from those in the old days: Instead of screens, slide projectors, or TV cameras, I now faced rows of inverted Heinz ketchup bottles. But the rest was familiar: the same facts, advice, questions, and even my jokes and their predictable responses. Everything about those talks came flooding back, including why I'd stopped giving them.

The public can't get enough medical news. What people really want to hear about are the breakthroughs and the exciting advances. Those of us who don't live on the clinical cutting edge have more mundane fare to offer, less like what comes from the lab bench or operating suite than what emanates from the pulpit.

Like pastors, we offer sage wisdom and sensible advice to people inclined to listen to us. They nod in agreement, and not much changes.

Also, like pastors, we don't give up. The same regulars come time after time, only maybe this time they'll pay closer attention so that our words hit home and nudge them a bit in the right direction.

So maybe that's why I agreed to speak. Or maybe I just like to talk.

I'm not sure why I agreed to speak at the mall, and gratis at that. Maybe it was nostalgia for the talks to community groups, primary care doctors, and television interviewers (at small, public-access stations) that I used to give when I was starting out. Or maybe it is because I just like to talk.

When I got to the local mall at 9:45 a.m., my hopes for a good crowd rose when I saw lines of people stretching out into the lobby. That lasted until I realized they were there for the Registry of Motor Vehicles.

My talk would be next door at the buffet restaurant. Posters announced this month's installment of the Health Awareness series, “Advances in Skin Cancer.” I met Janice, a twenty-something in charge of marketing for the strip mall. She led me inside the still-closed restaurant.

“Usually, they're done vacuuming before the lectures start,” she said. “You'll be speaking from here.” She pointed to a wood busing station against the near wall. I turned to face long, neat rows of small tables, each set with salt, pepper, ketchup, and steak sauce.

“How did you get my name?” I asked Janice.

“Google,” she replied. “Would you believe we called 30 dermatologists before we found you? The others were too busy or not interested.”

That was gratifying. “Do you get the same people coming to the lectures every month?”

“Pretty much,” she said as she indicated a list of regulars. “They check off their name so we can send them announcements.”

By then people started showing up. They all seemed to know Janice and each other. “These are good seats,” said one woman to her companion, taking a table in front.

Others shuffled in. By just after 10 a.m., 15 people had signed in and sat down. All were old and wan.

One woman sported a bulky gauze dressing on her left cheek. “My dermatologist took off a skin cancer this week,” she said, heading to her table.

“What kind of cancer was it?” I asked.

“I don't know,” she said. “I forgot to ask him.”

Janice offered no introduction. She distributed my one-page handout.

As instructed, I had brought no slides or PowerPoint presentations; the restaurant walls were unsuitable for either. My handout listed a number of Web sites on which to find pictures of skin cancer, though this crowd seemed unlikely to spend much time online.

I told them about basal and squamous cell carcinoma, melanoma, UVA and UVB, sunscreens, and vitamin D. I also mentioned tanning parlors, and we shared chuckles about the foolishness of kids.

One woman rose to testify. “I know my skin cancer came from a terrible sunburn on my chest,” she said. “My skin turned blue. Then I got this small, dark spot. One doctor said to forget about it, but I went to another one, and they did a test.”

I agreed that sunburns are undesirable, but suggested that a single bad one wouldn't necessarily generate cancer.

“What strength sunscreen do you recommend?” asked one woman.

“He already answered that,” said her table mate. “You have to pay attention!” I assumed this pair shared similar interchanges every month.

And so it went. The props were different from those in the old days: Instead of screens, slide projectors, or TV cameras, I now faced rows of inverted Heinz ketchup bottles. But the rest was familiar: the same facts, advice, questions, and even my jokes and their predictable responses. Everything about those talks came flooding back, including why I'd stopped giving them.

The public can't get enough medical news. What people really want to hear about are the breakthroughs and the exciting advances. Those of us who don't live on the clinical cutting edge have more mundane fare to offer, less like what comes from the lab bench or operating suite than what emanates from the pulpit.

Like pastors, we offer sage wisdom and sensible advice to people inclined to listen to us. They nod in agreement, and not much changes.

Also, like pastors, we don't give up. The same regulars come time after time, only maybe this time they'll pay closer attention so that our words hit home and nudge them a bit in the right direction.

So maybe that's why I agreed to speak. Or maybe I just like to talk.

From a recent article in the New York Times: “The Cleveland Clinic has lent its name and backup services to a string of CVS drugstore clinics in northeastern Ohio. And the Mayo Clinic is in the game, operating one Express Care clinic at a supermarket in Rochester, Minn.” (“Hospitals Begin to Move Into Supermarkets,” May 11, 2009).

“How may I help you?”

“I need frozen peas, strawberry jam, and a skin cancer screen.”

“Frozen peas, aisle 6; jams and preserves, aisle 8; skin screens right here.”

“Right here? Terrific.”

“Yes. Please undress and we'll have a look.”

“In the aisle?”

“Just kidding. You can proceed to the booth next to the deli counter. Have you seen a dermatologist lately?”

“Yes. I got a screen at CostSlasher last month.”

“Then why do you need another one?”

“I just finished a tanning series to get ready for a cruise, and I'm feeling guilty and vulnerable. Do you offer other services besides skin cancer screening?”

“Sure. What else have you got?”

“I have this wart on my index finger—OUCHHHH! What was that?”

“Liquid nitrogen. What else is going on?”

“I've been breaking out.”

“Cleansers, aisle 12, and here's a prescription.”

“Thanks. Can I fill it anywhere?”

“We have an exclusive with MachDonald's Pharmacy. Is there anything else?”

“My wife gave me a list. Let's see, laundry detergent, milk, whole wheat muffins—oh, yes, she wants you to look at this mole on my scalp. HEY, CUT THAT OUT!”

“I just performed a shave biopsy. We'll mail you the results next week with the next batch of coupons. Please take this card.”

“What is it?”

“Log onto our Web site and enter this eight-digit alphanumeric code. It makes you a member of our SuperSlashShopper VIP Club, which entitles you to one emergency appointment at one of our offices for the next 6 weeks.”

“Well, I guess all I need is that skin screen.”

“Before you get undressed, would you like e-mail updates about our specials?”

“No thanks.”

“In that case, I'll tell you about them now. Refer a friend or family member and get 15% off any three products in our signature, private-label skin care line.”

“Okay. I'll see.”

“Removal of pigmented spots, half price?”

“No thanks.”

“Laser off two blood vessels, get the third one free?”

“Not interested.”

“How about a package of three photorejuvenation sessions at 20% off?”

“No, thank you. Wait. I just remembered, my wife needs help with a coleslaw recipe using low-fat mayonnaise.”

“Mayo Clinic, aisle 3. Cleveland Clinic, aisle 2. Well, thanks for coming.”

“Hold on. What about my skin screen?”

“Sorry, I forgot. Why did you want another one?”

“I'm tanned, guilty, and vulnerable.”

“Right. In that case you should see my colleague.”

“What colleague?”

“A psychiatrist. He's in fresh produce, behind the broccoli. Next!”

From a recent article in the New York Times: “The Cleveland Clinic has lent its name and backup services to a string of CVS drugstore clinics in northeastern Ohio. And the Mayo Clinic is in the game, operating one Express Care clinic at a supermarket in Rochester, Minn.” (“Hospitals Begin to Move Into Supermarkets,” May 11, 2009).

“How may I help you?”

“I need frozen peas, strawberry jam, and a skin cancer screen.”

“Frozen peas, aisle 6; jams and preserves, aisle 8; skin screens right here.”

“Right here? Terrific.”

“Yes. Please undress and we'll have a look.”

“In the aisle?”

“Just kidding. You can proceed to the booth next to the deli counter. Have you seen a dermatologist lately?”

“Yes. I got a screen at CostSlasher last month.”

“Then why do you need another one?”

“I just finished a tanning series to get ready for a cruise, and I'm feeling guilty and vulnerable. Do you offer other services besides skin cancer screening?”

“Sure. What else have you got?”

“I have this wart on my index finger—OUCHHHH! What was that?”

“Liquid nitrogen. What else is going on?”

“I've been breaking out.”

“Cleansers, aisle 12, and here's a prescription.”

“Thanks. Can I fill it anywhere?”

“We have an exclusive with MachDonald's Pharmacy. Is there anything else?”

“My wife gave me a list. Let's see, laundry detergent, milk, whole wheat muffins—oh, yes, she wants you to look at this mole on my scalp. HEY, CUT THAT OUT!”

“I just performed a shave biopsy. We'll mail you the results next week with the next batch of coupons. Please take this card.”

“What is it?”

“Log onto our Web site and enter this eight-digit alphanumeric code. It makes you a member of our SuperSlashShopper VIP Club, which entitles you to one emergency appointment at one of our offices for the next 6 weeks.”

“Well, I guess all I need is that skin screen.”

“Before you get undressed, would you like e-mail updates about our specials?”

“No thanks.”

“In that case, I'll tell you about them now. Refer a friend or family member and get 15% off any three products in our signature, private-label skin care line.”

“Okay. I'll see.”

“Removal of pigmented spots, half price?”

“No thanks.”

“Laser off two blood vessels, get the third one free?”

“Not interested.”

“How about a package of three photorejuvenation sessions at 20% off?”

“No, thank you. Wait. I just remembered, my wife needs help with a coleslaw recipe using low-fat mayonnaise.”

“Mayo Clinic, aisle 3. Cleveland Clinic, aisle 2. Well, thanks for coming.”

“Hold on. What about my skin screen?”

“Sorry, I forgot. Why did you want another one?”

“I'm tanned, guilty, and vulnerable.”

“Right. In that case you should see my colleague.”

“What colleague?”

“A psychiatrist. He's in fresh produce, behind the broccoli. Next!”

From a recent article in the New York Times: “The Cleveland Clinic has lent its name and backup services to a string of CVS drugstore clinics in northeastern Ohio. And the Mayo Clinic is in the game, operating one Express Care clinic at a supermarket in Rochester, Minn.” (“Hospitals Begin to Move Into Supermarkets,” May 11, 2009).

“How may I help you?”

“I need frozen peas, strawberry jam, and a skin cancer screen.”

“Frozen peas, aisle 6; jams and preserves, aisle 8; skin screens right here.”

“Right here? Terrific.”

“Yes. Please undress and we'll have a look.”

“In the aisle?”

“Just kidding. You can proceed to the booth next to the deli counter. Have you seen a dermatologist lately?”

“Yes. I got a screen at CostSlasher last month.”

“Then why do you need another one?”

“I just finished a tanning series to get ready for a cruise, and I'm feeling guilty and vulnerable. Do you offer other services besides skin cancer screening?”

“Sure. What else have you got?”

“I have this wart on my index finger—OUCHHHH! What was that?”

“Liquid nitrogen. What else is going on?”

“I've been breaking out.”

“Cleansers, aisle 12, and here's a prescription.”

“Thanks. Can I fill it anywhere?”

“We have an exclusive with MachDonald's Pharmacy. Is there anything else?”

“My wife gave me a list. Let's see, laundry detergent, milk, whole wheat muffins—oh, yes, she wants you to look at this mole on my scalp. HEY, CUT THAT OUT!”

“I just performed a shave biopsy. We'll mail you the results next week with the next batch of coupons. Please take this card.”

“What is it?”

“Log onto our Web site and enter this eight-digit alphanumeric code. It makes you a member of our SuperSlashShopper VIP Club, which entitles you to one emergency appointment at one of our offices for the next 6 weeks.”

“Well, I guess all I need is that skin screen.”

“Before you get undressed, would you like e-mail updates about our specials?”

“No thanks.”

“In that case, I'll tell you about them now. Refer a friend or family member and get 15% off any three products in our signature, private-label skin care line.”

“Okay. I'll see.”

“Removal of pigmented spots, half price?”

“No thanks.”

“Laser off two blood vessels, get the third one free?”

“Not interested.”

“How about a package of three photorejuvenation sessions at 20% off?”

“No, thank you. Wait. I just remembered, my wife needs help with a coleslaw recipe using low-fat mayonnaise.”

“Mayo Clinic, aisle 3. Cleveland Clinic, aisle 2. Well, thanks for coming.”

“Hold on. What about my skin screen?”

“Sorry, I forgot. Why did you want another one?”

“I'm tanned, guilty, and vulnerable.”

“Right. In that case you should see my colleague.”

“What colleague?”

“A psychiatrist. He's in fresh produce, behind the broccoli. Next!”

I gave my name at the front desk of my new eye doctor. “Check in around the corner,” said the clerk.

Two front desks, apparently. The secretary at the second one handed me some pages of demographics and medical history to fill out. In the meantime, she chatted with her associates as she scanned my insurance card.

I sat in the waiting room as instructed. After a short while, a young man called my name. Since the ophthalmologist is a middle-aged woman, I realized at once that he was someone else.

“Hi, I'm Jeff,” he said cheerily, ushering me into an exam room where he started to test my vision. (“What's the lowest line you can read? What's clearer—1 or 2? 3 or 4?”)

After a few minutes, I softened my voice and said, “Please don't be offended. But who are you?”

“I'm Jeff,” he explained.

“Yes, but what is your role here, exactly, Jeff?”

“I'm an ophthalmic technician,” he said. “The doctor will see you when I'm done examining you and dilating your pupils.”

He proceeded. In our time together, I learned a few things about Jeff. (I'm nosy that way.) Being an ophthalmic tech was his second career. His first was building custom furniture, “until I blew out my shoulder helping a buddy on a weekend.” Jeff's first eye job was in the cornea department of a teaching hospital, until slow business there limited his advancement options. So far he liked private practice. He tapped clinical data onto the computer screen to his left.

I returned to the waiting room. Shortly after, I heard my name again and through a dilated blur recognized the doctor herself. Her examination was businesslike, punctuated by more taps of data onto the screen. “You have early cataracts,” she said. “Not clinically significant yet, but they are there.” She said I didn't need new glasses unless I wanted a different style. “See you in a year,” she said, exiting. I made that appointment at the first front desk.

There are many aspects that go into a good or service. There are codes for diagnosis and procedure; these generate a fee. There are measures of efficiency and outcome aiming to streamline medical services, make them uniform, and lately, rate those who provide them. Much power and money are at stake, not to mention quality, now being energetically defined.

It's therefore understandable that for these and other reasons, many doctors delegate history taking to medical assistants, then counseling to other personnel. The doctor just comes in for the core service, the part that counts.

This seems a shame, for reasons I think go beyond sentiment, though maybe I'm fooling myself. (Without knowing the patient's background, level of motivation, and attitude toward the recommended regimen, how do you know he or she will follow it?) But larger forces at play outweigh objections like these.

Anyhow, in my own small clinical domain, I can still learn some personal things about my patients, and act as though it matters. After all, I've known many of them for a long time, some for decades.

My own internist of 25 years limited his panel and joined a national concierge firm. A colleague upstairs agreed to take me on despite a closed practice. Stan, in practice since the mid-1970's, is one of only three physicians who's been in my building longer than I have. He is quite a throwback. He has a small office, one secretary, and takes the medical history himself (no sheets). He even does his own EKG's, if you can believe it. But he does use e-mail and responds promptly.

You get the feeling that Stan actually knows who his patients are.

Stan is a vigorous guy, and he looks to practice another 5 years. Once he hangs 'em up, I figure I'll find a concierge of my own. Sometimes when you want intimacy, or its illusion, you just have to pay for it.

I gave my name at the front desk of my new eye doctor. “Check in around the corner,” said the clerk.

Two front desks, apparently. The secretary at the second one handed me some pages of demographics and medical history to fill out. In the meantime, she chatted with her associates as she scanned my insurance card.

I sat in the waiting room as instructed. After a short while, a young man called my name. Since the ophthalmologist is a middle-aged woman, I realized at once that he was someone else.

“Hi, I'm Jeff,” he said cheerily, ushering me into an exam room where he started to test my vision. (“What's the lowest line you can read? What's clearer—1 or 2? 3 or 4?”)

After a few minutes, I softened my voice and said, “Please don't be offended. But who are you?”

“I'm Jeff,” he explained.

“Yes, but what is your role here, exactly, Jeff?”

“I'm an ophthalmic technician,” he said. “The doctor will see you when I'm done examining you and dilating your pupils.”

He proceeded. In our time together, I learned a few things about Jeff. (I'm nosy that way.) Being an ophthalmic tech was his second career. His first was building custom furniture, “until I blew out my shoulder helping a buddy on a weekend.” Jeff's first eye job was in the cornea department of a teaching hospital, until slow business there limited his advancement options. So far he liked private practice. He tapped clinical data onto the computer screen to his left.

I returned to the waiting room. Shortly after, I heard my name again and through a dilated blur recognized the doctor herself. Her examination was businesslike, punctuated by more taps of data onto the screen. “You have early cataracts,” she said. “Not clinically significant yet, but they are there.” She said I didn't need new glasses unless I wanted a different style. “See you in a year,” she said, exiting. I made that appointment at the first front desk.

There are many aspects that go into a good or service. There are codes for diagnosis and procedure; these generate a fee. There are measures of efficiency and outcome aiming to streamline medical services, make them uniform, and lately, rate those who provide them. Much power and money are at stake, not to mention quality, now being energetically defined.

It's therefore understandable that for these and other reasons, many doctors delegate history taking to medical assistants, then counseling to other personnel. The doctor just comes in for the core service, the part that counts.

This seems a shame, for reasons I think go beyond sentiment, though maybe I'm fooling myself. (Without knowing the patient's background, level of motivation, and attitude toward the recommended regimen, how do you know he or she will follow it?) But larger forces at play outweigh objections like these.

Anyhow, in my own small clinical domain, I can still learn some personal things about my patients, and act as though it matters. After all, I've known many of them for a long time, some for decades.

My own internist of 25 years limited his panel and joined a national concierge firm. A colleague upstairs agreed to take me on despite a closed practice. Stan, in practice since the mid-1970's, is one of only three physicians who's been in my building longer than I have. He is quite a throwback. He has a small office, one secretary, and takes the medical history himself (no sheets). He even does his own EKG's, if you can believe it. But he does use e-mail and responds promptly.

You get the feeling that Stan actually knows who his patients are.

Stan is a vigorous guy, and he looks to practice another 5 years. Once he hangs 'em up, I figure I'll find a concierge of my own. Sometimes when you want intimacy, or its illusion, you just have to pay for it.

I gave my name at the front desk of my new eye doctor. “Check in around the corner,” said the clerk.

Two front desks, apparently. The secretary at the second one handed me some pages of demographics and medical history to fill out. In the meantime, she chatted with her associates as she scanned my insurance card.

I sat in the waiting room as instructed. After a short while, a young man called my name. Since the ophthalmologist is a middle-aged woman, I realized at once that he was someone else.

“Hi, I'm Jeff,” he said cheerily, ushering me into an exam room where he started to test my vision. (“What's the lowest line you can read? What's clearer—1 or 2? 3 or 4?”)

After a few minutes, I softened my voice and said, “Please don't be offended. But who are you?”

“I'm Jeff,” he explained.

“Yes, but what is your role here, exactly, Jeff?”

“I'm an ophthalmic technician,” he said. “The doctor will see you when I'm done examining you and dilating your pupils.”

He proceeded. In our time together, I learned a few things about Jeff. (I'm nosy that way.) Being an ophthalmic tech was his second career. His first was building custom furniture, “until I blew out my shoulder helping a buddy on a weekend.” Jeff's first eye job was in the cornea department of a teaching hospital, until slow business there limited his advancement options. So far he liked private practice. He tapped clinical data onto the computer screen to his left.

I returned to the waiting room. Shortly after, I heard my name again and through a dilated blur recognized the doctor herself. Her examination was businesslike, punctuated by more taps of data onto the screen. “You have early cataracts,” she said. “Not clinically significant yet, but they are there.” She said I didn't need new glasses unless I wanted a different style. “See you in a year,” she said, exiting. I made that appointment at the first front desk.

There are many aspects that go into a good or service. There are codes for diagnosis and procedure; these generate a fee. There are measures of efficiency and outcome aiming to streamline medical services, make them uniform, and lately, rate those who provide them. Much power and money are at stake, not to mention quality, now being energetically defined.

It's therefore understandable that for these and other reasons, many doctors delegate history taking to medical assistants, then counseling to other personnel. The doctor just comes in for the core service, the part that counts.

This seems a shame, for reasons I think go beyond sentiment, though maybe I'm fooling myself. (Without knowing the patient's background, level of motivation, and attitude toward the recommended regimen, how do you know he or she will follow it?) But larger forces at play outweigh objections like these.

Anyhow, in my own small clinical domain, I can still learn some personal things about my patients, and act as though it matters. After all, I've known many of them for a long time, some for decades.

My own internist of 25 years limited his panel and joined a national concierge firm. A colleague upstairs agreed to take me on despite a closed practice. Stan, in practice since the mid-1970's, is one of only three physicians who's been in my building longer than I have. He is quite a throwback. He has a small office, one secretary, and takes the medical history himself (no sheets). He even does his own EKG's, if you can believe it. But he does use e-mail and responds promptly.

You get the feeling that Stan actually knows who his patients are.

Stan is a vigorous guy, and he looks to practice another 5 years. Once he hangs 'em up, I figure I'll find a concierge of my own. Sometimes when you want intimacy, or its illusion, you just have to pay for it.

It has been a tough week. If my staff ever decides to change careers, they should be well trained for work in a complaints department.

First there was Doris, a 50-something-year-old woman who's been my patient for years. Her rosacea flared up, so I wrote a prescription for doxycycline to help treat her face for her daughter's upcoming wedding. The next day I got a request that I fax another prescription to a mail-order pharmacy somewhere in Outer Darkness where rent and wages are low. Two days later the mail-order droid requested a clarification: hyclate or monohydrate? (Why does no other pharmacy ever ask me this?) I faxed back my answer.

Now here was Doris berating my secretary loudly and at length because the mail-order droid was still preparing her order. She demanded that we pay for overnight shipping to compensate for our sloppy incompetence. For good measure, she canceled her next appointment.

Asking us to pay for shipping was a new one. (A patient once did demand that I pay for dry-cleaning a dress when bacitracin from a dressing got on it.) I called Doris back, and left a polite voice mail message suggesting that she direct complaints of this nature to the mail-order pharmacy whose procedures were perhaps more pertinent than ours to her dilemma.

Later the same day Alfred came in, a slovenly and truculent man in his early 70s. His real concern was that we take off his facial keratoses. (You really can't tell a cosmetic patient by appearance.)

Alfred had a slightly raised patch on his right cheek that seemed at an earlier visit to be a vascular macule but had now developed a bit of texture. I explained that laser surgery would not work and suggested light curettage both to remove the spot and test it to rule out skin cancer.

Alfred would agree to this only if I guaranteed—in writing—that there would be no mark left afterward. I explained that I couldn't offer such a guarantee and why I felt it would be best to test the lesion (adding that leaving it there would guarantee that he would still have a spot). “Oh, so now we're just speculating,” he growled and walked out.

And you have a nice day too, sir.

The next day was even better. My PA, Megan, who has a soft manner and infinite patience, told me she had just endured a telephone tirade from a woman whose 21-year-old daughter had tinea of her toenails. We had actually diagnosed this 7 years earlier, offered the patient treatment with oral terbinafine, and asked her mother to arrange for liver function testing as a possible prelude to treatment.

They never got the testing done, and the patient had been back several times over the years for other issues without ever raising the fungal concern. Megan heard our mother patiently, spoke soothingly, and talked about treating with terbinafine when her daughter returned from school in May.

“In my family we don't use generics,” came her frosty reply.

I called Mom back. (At the time she was in Florida with her daughter, on spring break.) I explained that generic drugs can indeed be okay. (“I had a bad experience with one,” she reported.)

I told her that we could certainly start antifungal treatment after this semester, if her daughter wanted us to. And so on. She sounded mollified.

The question of course is: Why now? After having fungal toenails for 7 years, why did her daughter suddenly find it urgent to treat them? What about all those visits in between, spanning most of her adolescence?

People just get cranky, I suppose, and it was our misfortune to encounter three in a row. I guess I ought to make allowances for matrons aflutter in the run up to their daughter's wedding, or for gents who care deeply about their appearance, or for parents of excitable young ladies with acutely intolerable toenails, all of whom have decided to relieve their inner tension by beating up on me or my staff in full-throated arias of crankiness.

Only I'm feeling cranky myself just now, so I'm not in the mood for making allowances. You'll understand, won't you?

You won't? Too bad.

It has been a tough week. If my staff ever decides to change careers, they should be well trained for work in a complaints department.

First there was Doris, a 50-something-year-old woman who's been my patient for years. Her rosacea flared up, so I wrote a prescription for doxycycline to help treat her face for her daughter's upcoming wedding. The next day I got a request that I fax another prescription to a mail-order pharmacy somewhere in Outer Darkness where rent and wages are low. Two days later the mail-order droid requested a clarification: hyclate or monohydrate? (Why does no other pharmacy ever ask me this?) I faxed back my answer.

Now here was Doris berating my secretary loudly and at length because the mail-order droid was still preparing her order. She demanded that we pay for overnight shipping to compensate for our sloppy incompetence. For good measure, she canceled her next appointment.

Asking us to pay for shipping was a new one. (A patient once did demand that I pay for dry-cleaning a dress when bacitracin from a dressing got on it.) I called Doris back, and left a polite voice mail message suggesting that she direct complaints of this nature to the mail-order pharmacy whose procedures were perhaps more pertinent than ours to her dilemma.

Later the same day Alfred came in, a slovenly and truculent man in his early 70s. His real concern was that we take off his facial keratoses. (You really can't tell a cosmetic patient by appearance.)

Alfred had a slightly raised patch on his right cheek that seemed at an earlier visit to be a vascular macule but had now developed a bit of texture. I explained that laser surgery would not work and suggested light curettage both to remove the spot and test it to rule out skin cancer.

Alfred would agree to this only if I guaranteed—in writing—that there would be no mark left afterward. I explained that I couldn't offer such a guarantee and why I felt it would be best to test the lesion (adding that leaving it there would guarantee that he would still have a spot). “Oh, so now we're just speculating,” he growled and walked out.

And you have a nice day too, sir.

The next day was even better. My PA, Megan, who has a soft manner and infinite patience, told me she had just endured a telephone tirade from a woman whose 21-year-old daughter had tinea of her toenails. We had actually diagnosed this 7 years earlier, offered the patient treatment with oral terbinafine, and asked her mother to arrange for liver function testing as a possible prelude to treatment.

They never got the testing done, and the patient had been back several times over the years for other issues without ever raising the fungal concern. Megan heard our mother patiently, spoke soothingly, and talked about treating with terbinafine when her daughter returned from school in May.

“In my family we don't use generics,” came her frosty reply.

I called Mom back. (At the time she was in Florida with her daughter, on spring break.) I explained that generic drugs can indeed be okay. (“I had a bad experience with one,” she reported.)

I told her that we could certainly start antifungal treatment after this semester, if her daughter wanted us to. And so on. She sounded mollified.

The question of course is: Why now? After having fungal toenails for 7 years, why did her daughter suddenly find it urgent to treat them? What about all those visits in between, spanning most of her adolescence?

People just get cranky, I suppose, and it was our misfortune to encounter three in a row. I guess I ought to make allowances for matrons aflutter in the run up to their daughter's wedding, or for gents who care deeply about their appearance, or for parents of excitable young ladies with acutely intolerable toenails, all of whom have decided to relieve their inner tension by beating up on me or my staff in full-throated arias of crankiness.

Only I'm feeling cranky myself just now, so I'm not in the mood for making allowances. You'll understand, won't you?

You won't? Too bad.

It has been a tough week. If my staff ever decides to change careers, they should be well trained for work in a complaints department.

First there was Doris, a 50-something-year-old woman who's been my patient for years. Her rosacea flared up, so I wrote a prescription for doxycycline to help treat her face for her daughter's upcoming wedding. The next day I got a request that I fax another prescription to a mail-order pharmacy somewhere in Outer Darkness where rent and wages are low. Two days later the mail-order droid requested a clarification: hyclate or monohydrate? (Why does no other pharmacy ever ask me this?) I faxed back my answer.

Now here was Doris berating my secretary loudly and at length because the mail-order droid was still preparing her order. She demanded that we pay for overnight shipping to compensate for our sloppy incompetence. For good measure, she canceled her next appointment.

Asking us to pay for shipping was a new one. (A patient once did demand that I pay for dry-cleaning a dress when bacitracin from a dressing got on it.) I called Doris back, and left a polite voice mail message suggesting that she direct complaints of this nature to the mail-order pharmacy whose procedures were perhaps more pertinent than ours to her dilemma.

Later the same day Alfred came in, a slovenly and truculent man in his early 70s. His real concern was that we take off his facial keratoses. (You really can't tell a cosmetic patient by appearance.)

Alfred had a slightly raised patch on his right cheek that seemed at an earlier visit to be a vascular macule but had now developed a bit of texture. I explained that laser surgery would not work and suggested light curettage both to remove the spot and test it to rule out skin cancer.

Alfred would agree to this only if I guaranteed—in writing—that there would be no mark left afterward. I explained that I couldn't offer such a guarantee and why I felt it would be best to test the lesion (adding that leaving it there would guarantee that he would still have a spot). “Oh, so now we're just speculating,” he growled and walked out.

And you have a nice day too, sir.

The next day was even better. My PA, Megan, who has a soft manner and infinite patience, told me she had just endured a telephone tirade from a woman whose 21-year-old daughter had tinea of her toenails. We had actually diagnosed this 7 years earlier, offered the patient treatment with oral terbinafine, and asked her mother to arrange for liver function testing as a possible prelude to treatment.

They never got the testing done, and the patient had been back several times over the years for other issues without ever raising the fungal concern. Megan heard our mother patiently, spoke soothingly, and talked about treating with terbinafine when her daughter returned from school in May.

“In my family we don't use generics,” came her frosty reply.

I called Mom back. (At the time she was in Florida with her daughter, on spring break.) I explained that generic drugs can indeed be okay. (“I had a bad experience with one,” she reported.)

I told her that we could certainly start antifungal treatment after this semester, if her daughter wanted us to. And so on. She sounded mollified.

The question of course is: Why now? After having fungal toenails for 7 years, why did her daughter suddenly find it urgent to treat them? What about all those visits in between, spanning most of her adolescence?

People just get cranky, I suppose, and it was our misfortune to encounter three in a row. I guess I ought to make allowances for matrons aflutter in the run up to their daughter's wedding, or for gents who care deeply about their appearance, or for parents of excitable young ladies with acutely intolerable toenails, all of whom have decided to relieve their inner tension by beating up on me or my staff in full-throated arias of crankiness.

Only I'm feeling cranky myself just now, so I'm not in the mood for making allowances. You'll understand, won't you?

You won't? Too bad.

Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.

About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.

“Oh, about a month,” she said, indifferently.

Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.

But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?

I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?

Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.

Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.

I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”

His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.

But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.

The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.

I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.

Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.

About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.

“Oh, about a month,” she said, indifferently.

Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.

But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?

I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?

Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.

Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.

I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”

His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.

But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.

The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.

I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.

Stella seems like a sensible woman. She has had two basal cells removed, so she comes regularly for me to check her sun-damaged skin.

About 4 years ago, I prevailed on Stella to let me examine her in full, something she had insisted wasn't necessary. I was almost done, when I looked under her bra and noticed something. Further inspection showed both her breasts completely covered with a deep-red, erosive rash. Taken aback, I asked her how long this had been there.

“Oh, about a month,” she said, indifferently.

Not terribly likely. Biopsy showed Paget's disease. She had this treated, along with the intraductal breast carcinoma beneath it. Stella continues to come once a year, and she still gives the impression of being level-headed and sensible.

But I have to ask myself: All that time (months? years?), whenever this sensible woman undressed or showered and saw her breasts, what was she thinking? That they were supposed to look that way? That what was staring her in the face really wasn't there?

I ask myself the same about Robert, an amiable if absent-minded professor with a bushy red beard. Underneath the hair on his left cheek he had a gaping, oozing hole. Who knows how long that had been there? Although his beard made this chasm—which turned out to be a huge basal cell—invisible to onlookers, Robert must surely have washed his face now and then. What was he thinking when he touched or saw this defect, which measured several centimeters in diameter by the time he showed up in my office? That oozing holes belong on the face?

Like Stella, Robert readily agreed to take care of his cancer. He follows up regularly, showing no sign of being delusional, or even much odder than the average professor.

Denial is indeed a powerful thing. It helps people ignore what is right before their eyes.

I can think back over the years to spectacular instances like those of Stella and Robert, patients who let visible cancers grow and fester for decades. Twenty years ago a patient phoned. “My wife is coming to see you,” he said, “and I want you to know in advance that we're aware we have a problem, and we're working on it.” I asked him what he was talking about. “We've been married 12 years,” he said, “and she's never taken off her shirt.”

His wife turned out to be a globetrotting business executive in her mid 30s. She showed me a basal cell that extended from her suprasternal notch to her left shoulder.

But there also have been many less dramatic examples of people who just couldn't be bothered to take care of things they knew they had to treat, or to follow up on what they agreed they ought to. Some claimed they were too busy, others were clearly afraid of bad news. So they looked at themselves with eyes wide shut.

The lesson I draw from behavior like this is that we can't simply assume our patients will act in their own best interests—that they will get a skin cancer removed because we told them they have one, or that they will come back regularly because they're at high risk. Beyond making a recommendation, we need to check whether they followed it and badger them if they haven't.

I sometimes shrug when experts—from economists to ethicists—describe people as rational actors who make sound decisions to advance their interests as long as they have the proper data with which to do so. I wonder which people they have in mind. They obviously can't mean Stella and Robert, and many other people I meet every day.

Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”

I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.

Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”

You would think that, after 30 years, I would recognize a basal cell.

Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.

In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?

The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.

Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?

We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”

We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.

Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.

Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”

Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”

I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.

As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.

Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.

Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”

I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.

Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”

You would think that, after 30 years, I would recognize a basal cell.

Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.

In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?

The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.

Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?

We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”

We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.

Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.

Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”

Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”

I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.

As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.

Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.

Jenna wanted to show me something on her lip before she and her young family moved to Berlin in 5 days. “This has been here for a year,” she said. “I think it may have grown.”

I stared at it in bright light, with high magnification. “It looks like a large pore,” I said. “It's small and perfectly round. I don't think it's a problem.” I suggested she e-mail me if she had any concerns while she got settled.

Two months later, Jenna did just that, telling me that the lip spot had grown. I sent her the names of AAD-affiliated dermatologists in Berlin. Shortly afterward, she wrote again. “What you said was a 'pore' is actually a basal cell skin cancer. I'm disappointed that it wasn't diagnosed earlier.”

You would think that, after 30 years, I would recognize a basal cell.

Everyone knows that humans make mistakes, but it's hard to admit that we are that human. This is true even if the mistake isn't likely to result in a lawsuit. Admitting fallibility is hard, especially for doctors. So often patients put us on a pedestal, whether we deserve to be up there or not, and it's tough to climb off.

In our professional role, we are calm and competent. People come to us when they're in trouble and count on us to get things right. If we let them down, can they trust us next time around? Can we trust ourselves?

The answer to whether they can trust us again is often no. Even after a warm clinical relationship spanning years, a missed diagnosis may be followed by a signed request to “Forward my records to …” It doesn't matter how many correct diagnoses came before, how many ultraprecautionary biopsies were negative; sometimes one strike and you're out. This may seem unfair but is really no more than the flip side of all that unmerited adulation.

Anyone in practice long enough gets his or her share of letters expressing anger or disappointment. Sending a response that aims at self-justification is usually unhelpful, if not useless. But who among us is courageous—or foolish—enough to say, “Sorry, but you're right—I blew it”?

We dermatologists can make relatively few errors that have dire or irreversible consequences. Missing a melanoma is, of course, such a mistake. Yet despite hypervigilance, careful examination, and frequent biopsy, there will always be that funny lesion that doesn't look the way a melanoma should, about which the patient, or attorney, will demand, “Why didn't you test that, Doctor?”

We might respond to this circumstance with frustration or a guilty conscience. Either way, it's embarrassing to admit we came up short. Now and then, a patient or relative will rub in our shortcoming with particular relish.

Last year, I diagnosed and treated a basal cell on the forehead of an elderly Russian woman. She returned a few months later to show me another spot on her upper lip. “You said it was okay,” she said, “but my daughter is worried.” I could barely see the lesion, but the biopsy confirmed that it too was a basal cell.

Her daughter, who turned out to be a family practitioner, called soon after. “Tell me,” she said, her voice heavy with sarcasm, “when you look at the forehead, do you also look a few centimeters down to the lip, or is that too much trouble?”

Taken aback, I offered no response. “My mother has a daughter who is a physician,” she went on. “What happens to your patients who don't have that luxury?”

I could have responded by hoping that if she herself ever makes an error, her patients might be more forbearing. But I said only that I understood her point.

As for Jenna, I answered by saying that her lip lesion had not looked to me like a basal cell and that I tried to avoid biopsies on the faces of young people if I couldn't justify them. I added that I was sure she would be well taken care of.

Hippocrates had it right: Life is short, the art long, opportunity fleeting, experience misleading, judgment difficult. We just have to keep trying.