Under My Skin

As Dr. Gregory Samplingerror awoke one morning, he found that he had been demoted overnight to a ridiculous second-tier physician.

"I cannot go to the office," he thought. "All the patients will see the change in me at once. And even if they don't, they will realize it when they find their copayment is $10 more."

Gregory called his new secretary, Ms. W, and told her to close his schedule indefinitely, as something had come up. He could tell that Ms. W knew the reason.

Gregory unfolded the official notice. "You have been assigned to Tier Two," it read. "You have been tiered at the customer service unit [CSU] group level, according to your LCU/CSU."

"This must be some mistake," thought Gregory as he showered and dressed. He chose a charcoal gray suit, dark blue tie, black trench coat, and bowler—attire befitting a Tier One physician. "I will straighten things out at once by contacting my LCU Medical Director, as instructed," he said. "But first I must learn what an LCU is."

Pulling up his collar and drawing his bowler down over his eyes, Gregory set out for an unfamiliar district. Rows of gray apartment blocks lined both sides of the street. Unemployed men in shirtsleeves idled on balconies, toasting marshmallows. A young woman took Gregory's arm. "I see you are lost," she said, handing him a marshmallow. "The local care unit is there," she said, "third floor." Then she was gone.

On the third landing, a uniformed guard leafed through a dog-eared ICD-9 manual. He eyed Gregory with a sardonic smile.

"I must see the director," said Gregory. "By some mistake, I have been …"

"Designated Tier Two," said the guard, with a show of indifference. "The director is out," he added.

"When will he return?" asked Gregory.

"Afterward, possibly," said the guard, offering Gregory a chair.

Three months later, Gregory asked, "Is there someone else I can see about this?"

"The deputy director is in," said the guard, "but I warn you that he can do nothing. However, you may suit yourself. Third office on the right."

Eager to be heard at last, Gregory hurried to the office near the end of the corridor, where he found the deputy director at his desk, wearing a green eyeshade, smoking a fine Havana cigar. "Please come in," he said, "but I cannot help you."

"Why have I been designated Tier Two?" asked Gregory.

"Our clinical performance improvement initiative," said the deputy director, "incorporates principles agreed upon by local or national stakeholder groups. ETG methodology was used as the basis for efficiency analysis. Please take off your hat."

"What is an ETG?" asked Gregory.

"Episode Treatment Group," said the deputy director. "It measures your quality and efficiency compared to those of your peers in treating episodes. These measures have been validated by RHI, HEDIS, and AHRQ. Cigar?"

Gregory declined. "Can you tell me what I've done wrong?" he asked.

"No," said the deputy director. "The director might be able to, but he is out. In any case, he takes directives from the Group Insurance Commission, which has mandated quality measures. Our job is merely to implement their mandate."

"Where is their office?" asked Gregory.

"They don't have one," the deputy director said. "And now, if you'll please excuse me …"

"But wait," said Gregory, who was beginning to grow alarmed. "Why has the GIC done this?"

The deputy director aimed a contemplative puff across his desk. "To address rising health care costs and reduced employer coverage, the GIC has demanded incentives for consumers to make more informed choices about health care options and for providers to examine their practices relative to their use of resources compared to their peers."

"Is it clear that consumers will change doctors to save $10 on a copayment?" asked Gregory.

"Not yet," said the deputy director. "However, we have identified a problem and taken a proactive step."

"But how can I rise to Tier One," said Gregory, "when I don't know what I did to sink into Tier Two?"

"For one thing," snapped the deputy director, "you could improve your relative score! Look at this!" he demanded, brandishing a sheet of white paper. "A q-score of 1.3! A resource utilization score of 1.16! Outlying performance on ETG 675, 'Fungal skin infection w/o major surgery'! Disgraceful! If we labeled you Tier One, how could we justify our fiduciary stance to our stakeholders?"

"Do the stakeholders have an office?" asked Gregory, who was trembling now. "I can explain …"

"They have no office," said the deputy director, ushering Gregory to the door and handing him his bowler. "They are outside, holding the stakes."

Gregory stumbled down the stairs, the laughter of the guard and deputy director ringing in his ears. Outside, barefoot children mocked him. "Tier Two, Tier Two!" they jeered. A pair of impassive, shirtsleeved men Gregory recognized from the balcony approached with sharp, pointed sticks. Each took him by one arm. "Who are you?" asked Gregory. "We are the stakeholders," said one. "But where are we going?" asked Gregory. "To toast marshmallows," said the other.

"And you, Dr. Gregory Samplingerror," said the other, "are the marshmallow."

As Dr. Gregory Samplingerror awoke one morning, he found that he had been demoted overnight to a ridiculous second-tier physician.

"I cannot go to the office," he thought. "All the patients will see the change in me at once. And even if they don't, they will realize it when they find their copayment is $10 more."

Gregory called his new secretary, Ms. W, and told her to close his schedule indefinitely, as something had come up. He could tell that Ms. W knew the reason.

Gregory unfolded the official notice. "You have been assigned to Tier Two," it read. "You have been tiered at the customer service unit [CSU] group level, according to your LCU/CSU."

"This must be some mistake," thought Gregory as he showered and dressed. He chose a charcoal gray suit, dark blue tie, black trench coat, and bowler—attire befitting a Tier One physician. "I will straighten things out at once by contacting my LCU Medical Director, as instructed," he said. "But first I must learn what an LCU is."

Pulling up his collar and drawing his bowler down over his eyes, Gregory set out for an unfamiliar district. Rows of gray apartment blocks lined both sides of the street. Unemployed men in shirtsleeves idled on balconies, toasting marshmallows. A young woman took Gregory's arm. "I see you are lost," she said, handing him a marshmallow. "The local care unit is there," she said, "third floor." Then she was gone.

On the third landing, a uniformed guard leafed through a dog-eared ICD-9 manual. He eyed Gregory with a sardonic smile.

"I must see the director," said Gregory. "By some mistake, I have been …"

"Designated Tier Two," said the guard, with a show of indifference. "The director is out," he added.

"When will he return?" asked Gregory.

"Afterward, possibly," said the guard, offering Gregory a chair.

Three months later, Gregory asked, "Is there someone else I can see about this?"

"The deputy director is in," said the guard, "but I warn you that he can do nothing. However, you may suit yourself. Third office on the right."

Eager to be heard at last, Gregory hurried to the office near the end of the corridor, where he found the deputy director at his desk, wearing a green eyeshade, smoking a fine Havana cigar. "Please come in," he said, "but I cannot help you."

"Why have I been designated Tier Two?" asked Gregory.

"Our clinical performance improvement initiative," said the deputy director, "incorporates principles agreed upon by local or national stakeholder groups. ETG methodology was used as the basis for efficiency analysis. Please take off your hat."

"What is an ETG?" asked Gregory.

"Episode Treatment Group," said the deputy director. "It measures your quality and efficiency compared to those of your peers in treating episodes. These measures have been validated by RHI, HEDIS, and AHRQ. Cigar?"

Gregory declined. "Can you tell me what I've done wrong?" he asked.

"No," said the deputy director. "The director might be able to, but he is out. In any case, he takes directives from the Group Insurance Commission, which has mandated quality measures. Our job is merely to implement their mandate."

"Where is their office?" asked Gregory.

"They don't have one," the deputy director said. "And now, if you'll please excuse me …"

"But wait," said Gregory, who was beginning to grow alarmed. "Why has the GIC done this?"

The deputy director aimed a contemplative puff across his desk. "To address rising health care costs and reduced employer coverage, the GIC has demanded incentives for consumers to make more informed choices about health care options and for providers to examine their practices relative to their use of resources compared to their peers."

"Is it clear that consumers will change doctors to save $10 on a copayment?" asked Gregory.

"Not yet," said the deputy director. "However, we have identified a problem and taken a proactive step."

"But how can I rise to Tier One," said Gregory, "when I don't know what I did to sink into Tier Two?"

"For one thing," snapped the deputy director, "you could improve your relative score! Look at this!" he demanded, brandishing a sheet of white paper. "A q-score of 1.3! A resource utilization score of 1.16! Outlying performance on ETG 675, 'Fungal skin infection w/o major surgery'! Disgraceful! If we labeled you Tier One, how could we justify our fiduciary stance to our stakeholders?"

"Do the stakeholders have an office?" asked Gregory, who was trembling now. "I can explain …"

"They have no office," said the deputy director, ushering Gregory to the door and handing him his bowler. "They are outside, holding the stakes."

Gregory stumbled down the stairs, the laughter of the guard and deputy director ringing in his ears. Outside, barefoot children mocked him. "Tier Two, Tier Two!" they jeered. A pair of impassive, shirtsleeved men Gregory recognized from the balcony approached with sharp, pointed sticks. Each took him by one arm. "Who are you?" asked Gregory. "We are the stakeholders," said one. "But where are we going?" asked Gregory. "To toast marshmallows," said the other.

"And you, Dr. Gregory Samplingerror," said the other, "are the marshmallow."

As Dr. Gregory Samplingerror awoke one morning, he found that he had been demoted overnight to a ridiculous second-tier physician.

"I cannot go to the office," he thought. "All the patients will see the change in me at once. And even if they don't, they will realize it when they find their copayment is $10 more."

Gregory called his new secretary, Ms. W, and told her to close his schedule indefinitely, as something had come up. He could tell that Ms. W knew the reason.

Gregory unfolded the official notice. "You have been assigned to Tier Two," it read. "You have been tiered at the customer service unit [CSU] group level, according to your LCU/CSU."

"This must be some mistake," thought Gregory as he showered and dressed. He chose a charcoal gray suit, dark blue tie, black trench coat, and bowler—attire befitting a Tier One physician. "I will straighten things out at once by contacting my LCU Medical Director, as instructed," he said. "But first I must learn what an LCU is."

Pulling up his collar and drawing his bowler down over his eyes, Gregory set out for an unfamiliar district. Rows of gray apartment blocks lined both sides of the street. Unemployed men in shirtsleeves idled on balconies, toasting marshmallows. A young woman took Gregory's arm. "I see you are lost," she said, handing him a marshmallow. "The local care unit is there," she said, "third floor." Then she was gone.

On the third landing, a uniformed guard leafed through a dog-eared ICD-9 manual. He eyed Gregory with a sardonic smile.

"I must see the director," said Gregory. "By some mistake, I have been …"

"Designated Tier Two," said the guard, with a show of indifference. "The director is out," he added.

"When will he return?" asked Gregory.

"Afterward, possibly," said the guard, offering Gregory a chair.

Three months later, Gregory asked, "Is there someone else I can see about this?"

"The deputy director is in," said the guard, "but I warn you that he can do nothing. However, you may suit yourself. Third office on the right."

Eager to be heard at last, Gregory hurried to the office near the end of the corridor, where he found the deputy director at his desk, wearing a green eyeshade, smoking a fine Havana cigar. "Please come in," he said, "but I cannot help you."

"Why have I been designated Tier Two?" asked Gregory.

"Our clinical performance improvement initiative," said the deputy director, "incorporates principles agreed upon by local or national stakeholder groups. ETG methodology was used as the basis for efficiency analysis. Please take off your hat."

"What is an ETG?" asked Gregory.

"Episode Treatment Group," said the deputy director. "It measures your quality and efficiency compared to those of your peers in treating episodes. These measures have been validated by RHI, HEDIS, and AHRQ. Cigar?"

Gregory declined. "Can you tell me what I've done wrong?" he asked.

"No," said the deputy director. "The director might be able to, but he is out. In any case, he takes directives from the Group Insurance Commission, which has mandated quality measures. Our job is merely to implement their mandate."

"Where is their office?" asked Gregory.

"They don't have one," the deputy director said. "And now, if you'll please excuse me …"

"But wait," said Gregory, who was beginning to grow alarmed. "Why has the GIC done this?"

The deputy director aimed a contemplative puff across his desk. "To address rising health care costs and reduced employer coverage, the GIC has demanded incentives for consumers to make more informed choices about health care options and for providers to examine their practices relative to their use of resources compared to their peers."

"Is it clear that consumers will change doctors to save $10 on a copayment?" asked Gregory.

"Not yet," said the deputy director. "However, we have identified a problem and taken a proactive step."

"But how can I rise to Tier One," said Gregory, "when I don't know what I did to sink into Tier Two?"

"For one thing," snapped the deputy director, "you could improve your relative score! Look at this!" he demanded, brandishing a sheet of white paper. "A q-score of 1.3! A resource utilization score of 1.16! Outlying performance on ETG 675, 'Fungal skin infection w/o major surgery'! Disgraceful! If we labeled you Tier One, how could we justify our fiduciary stance to our stakeholders?"

"Do the stakeholders have an office?" asked Gregory, who was trembling now. "I can explain …"

"They have no office," said the deputy director, ushering Gregory to the door and handing him his bowler. "They are outside, holding the stakes."

Gregory stumbled down the stairs, the laughter of the guard and deputy director ringing in his ears. Outside, barefoot children mocked him. "Tier Two, Tier Two!" they jeered. A pair of impassive, shirtsleeved men Gregory recognized from the balcony approached with sharp, pointed sticks. Each took him by one arm. "Who are you?" asked Gregory. "We are the stakeholders," said one. "But where are we going?" asked Gregory. "To toast marshmallows," said the other.

"And you, Dr. Gregory Samplingerror," said the other, "are the marshmallow."

How long does it take for a red spot to go away?

Well, it depends on what kind of spot, where it is, whether it's been picked at, and so on. But just because there's no straight answer doesn't stop patients from providing one themselves, and then drawing inferences that don't do any good for their prospects or peace of mind.

Many people use the rate at which red spots fade as an index of their overall health, and slow fading means poor healing. The two commonest states for which this is supposed to be a feature are diabetes and old age. Once someone is diagnosed with the former or assigned (by himself or someone else) to the latter, he takes note of a red spot (a scratch, a surgical scar), decides that it's taking too long to go away (has he ever looked before?), and concludes, "I don't heal as well as I used to."

Physicians sometimes reinforce this by telling him that diabetics have "poor healing," from which he deduces, not unreasonably, that any innocent nick can be just around the corner from gangrene. (Most of my diabetic patients seem to heal just as fast as anybody else.)

In this way, persistent redness can imply something about overall state of health. Besides that, redness—which lies right out there on the skin, our territory—can take on specific meaning in several situations we meet every day.

▸ "My acne is starting to scar." Departed inflammatory acne lesions often leave red marks that take some time to fade. How long depends on their depth, state of excoriation, and/or no apparent reason. Some acne patients think of comedones and small papules as more or less normal and don't even come in for treatment until they notice that their spots are taking too long to go away. They refer to this as scarring, by which they don't necessarily mean what we mean by this term, namely permanence.

Acne treatment may fail for many reasons, but one common cause—left out by the promulgators of those accursed algorithms—is despair. The patient sees marks that stay reddish for weeks and picks at them in frustration (which of course perpetuates them). Confronted every day in the mirror with the same two dozen livid marks, she decides that our treatment is a waste of time. Why wouldn't she?

Unless we supplement our treatment, whatever it is, with constant hand holding and reassurance that yes, Virginia, those red spots really do fade over months if they're left utterly alone, and makeup is really okay to use because it won't clog your pores, she'll never get better.

▸ How about some leg makeup? For some reason, red marks take longer to fade the lower down on the body they are. Even when psoriatic plaques flatten, ugly purple splotches persist. These hang around for months, and they may not look improved to patients who aren't explicitly told that indeed they are. Then, of course, there are those with stasis dermatitis who fail to respond to antibiotic therapy for "bilateral cellulitis." After all, the legs still look just as red. …

▸ Red scrotums in the sunset. I often encounter patients, in the office or in online chat rooms, who are convinced that their penises and scrotums are tingly, sensitive, and altogether "too red." One common scenario is this: The patient had balanitis, dermatitis, or perhaps a marathon evening of passion in Bangkok's red-light district. Beset by fear or guilt, he consults a physician, who diagnoses it as (what else?) a fungus.

An endless treatment sequence ensues: antifungal creams, antibacterials, and cortisones. This helps the patient focus on his nether regions and therefore feel all kinds of sensations and notice redness he's quite sure "wasn't there before." Needless to say, he's never stared down there before with this kind of focus until he thought he had an STD or a fungus.

The approach I've found most useful in such cases, once it's clear that there is no active disease, is to tell him to stop absolutely all active remedies, to use only unmedicated moisture lotions, to ignore any tingling as irrelevant, and to look unfailingly up, not down. Eventually, either the redness finally goes away or the patient does, having concluded that whatever the color is really belongs there after all.

How long does it take for a red spot to go away?

Well, it depends on what kind of spot, where it is, whether it's been picked at, and so on. But just because there's no straight answer doesn't stop patients from providing one themselves, and then drawing inferences that don't do any good for their prospects or peace of mind.

Many people use the rate at which red spots fade as an index of their overall health, and slow fading means poor healing. The two commonest states for which this is supposed to be a feature are diabetes and old age. Once someone is diagnosed with the former or assigned (by himself or someone else) to the latter, he takes note of a red spot (a scratch, a surgical scar), decides that it's taking too long to go away (has he ever looked before?), and concludes, "I don't heal as well as I used to."

Physicians sometimes reinforce this by telling him that diabetics have "poor healing," from which he deduces, not unreasonably, that any innocent nick can be just around the corner from gangrene. (Most of my diabetic patients seem to heal just as fast as anybody else.)

In this way, persistent redness can imply something about overall state of health. Besides that, redness—which lies right out there on the skin, our territory—can take on specific meaning in several situations we meet every day.

▸ "My acne is starting to scar." Departed inflammatory acne lesions often leave red marks that take some time to fade. How long depends on their depth, state of excoriation, and/or no apparent reason. Some acne patients think of comedones and small papules as more or less normal and don't even come in for treatment until they notice that their spots are taking too long to go away. They refer to this as scarring, by which they don't necessarily mean what we mean by this term, namely permanence.

Acne treatment may fail for many reasons, but one common cause—left out by the promulgators of those accursed algorithms—is despair. The patient sees marks that stay reddish for weeks and picks at them in frustration (which of course perpetuates them). Confronted every day in the mirror with the same two dozen livid marks, she decides that our treatment is a waste of time. Why wouldn't she?

Unless we supplement our treatment, whatever it is, with constant hand holding and reassurance that yes, Virginia, those red spots really do fade over months if they're left utterly alone, and makeup is really okay to use because it won't clog your pores, she'll never get better.

▸ How about some leg makeup? For some reason, red marks take longer to fade the lower down on the body they are. Even when psoriatic plaques flatten, ugly purple splotches persist. These hang around for months, and they may not look improved to patients who aren't explicitly told that indeed they are. Then, of course, there are those with stasis dermatitis who fail to respond to antibiotic therapy for "bilateral cellulitis." After all, the legs still look just as red. …

▸ Red scrotums in the sunset. I often encounter patients, in the office or in online chat rooms, who are convinced that their penises and scrotums are tingly, sensitive, and altogether "too red." One common scenario is this: The patient had balanitis, dermatitis, or perhaps a marathon evening of passion in Bangkok's red-light district. Beset by fear or guilt, he consults a physician, who diagnoses it as (what else?) a fungus.

An endless treatment sequence ensues: antifungal creams, antibacterials, and cortisones. This helps the patient focus on his nether regions and therefore feel all kinds of sensations and notice redness he's quite sure "wasn't there before." Needless to say, he's never stared down there before with this kind of focus until he thought he had an STD or a fungus.

The approach I've found most useful in such cases, once it's clear that there is no active disease, is to tell him to stop absolutely all active remedies, to use only unmedicated moisture lotions, to ignore any tingling as irrelevant, and to look unfailingly up, not down. Eventually, either the redness finally goes away or the patient does, having concluded that whatever the color is really belongs there after all.

How long does it take for a red spot to go away?

Well, it depends on what kind of spot, where it is, whether it's been picked at, and so on. But just because there's no straight answer doesn't stop patients from providing one themselves, and then drawing inferences that don't do any good for their prospects or peace of mind.

Many people use the rate at which red spots fade as an index of their overall health, and slow fading means poor healing. The two commonest states for which this is supposed to be a feature are diabetes and old age. Once someone is diagnosed with the former or assigned (by himself or someone else) to the latter, he takes note of a red spot (a scratch, a surgical scar), decides that it's taking too long to go away (has he ever looked before?), and concludes, "I don't heal as well as I used to."

Physicians sometimes reinforce this by telling him that diabetics have "poor healing," from which he deduces, not unreasonably, that any innocent nick can be just around the corner from gangrene. (Most of my diabetic patients seem to heal just as fast as anybody else.)

In this way, persistent redness can imply something about overall state of health. Besides that, redness—which lies right out there on the skin, our territory—can take on specific meaning in several situations we meet every day.

▸ "My acne is starting to scar." Departed inflammatory acne lesions often leave red marks that take some time to fade. How long depends on their depth, state of excoriation, and/or no apparent reason. Some acne patients think of comedones and small papules as more or less normal and don't even come in for treatment until they notice that their spots are taking too long to go away. They refer to this as scarring, by which they don't necessarily mean what we mean by this term, namely permanence.

Acne treatment may fail for many reasons, but one common cause—left out by the promulgators of those accursed algorithms—is despair. The patient sees marks that stay reddish for weeks and picks at them in frustration (which of course perpetuates them). Confronted every day in the mirror with the same two dozen livid marks, she decides that our treatment is a waste of time. Why wouldn't she?

Unless we supplement our treatment, whatever it is, with constant hand holding and reassurance that yes, Virginia, those red spots really do fade over months if they're left utterly alone, and makeup is really okay to use because it won't clog your pores, she'll never get better.

▸ How about some leg makeup? For some reason, red marks take longer to fade the lower down on the body they are. Even when psoriatic plaques flatten, ugly purple splotches persist. These hang around for months, and they may not look improved to patients who aren't explicitly told that indeed they are. Then, of course, there are those with stasis dermatitis who fail to respond to antibiotic therapy for "bilateral cellulitis." After all, the legs still look just as red. …

▸ Red scrotums in the sunset. I often encounter patients, in the office or in online chat rooms, who are convinced that their penises and scrotums are tingly, sensitive, and altogether "too red." One common scenario is this: The patient had balanitis, dermatitis, or perhaps a marathon evening of passion in Bangkok's red-light district. Beset by fear or guilt, he consults a physician, who diagnoses it as (what else?) a fungus.

An endless treatment sequence ensues: antifungal creams, antibacterials, and cortisones. This helps the patient focus on his nether regions and therefore feel all kinds of sensations and notice redness he's quite sure "wasn't there before." Needless to say, he's never stared down there before with this kind of focus until he thought he had an STD or a fungus.

The approach I've found most useful in such cases, once it's clear that there is no active disease, is to tell him to stop absolutely all active remedies, to use only unmedicated moisture lotions, to ignore any tingling as irrelevant, and to look unfailingly up, not down. Eventually, either the redness finally goes away or the patient does, having concluded that whatever the color is really belongs there after all.

Now that the Feds are pushing them, there's a lot of buzz about electronic medical records, which most physicians have not yet implemented. I put in computerized patient records in 1989. Bully for me.

Because I'm neither technological nor gadgety, I think I did it to save space and filing time and avoid lost records. The space saving was nice, but I didn't know yet that computers lose records, too.

The computer firm I dealt with was a one-man show, so a few years later, I decided to advance to a larger operation that promised to do niftier things. Could they save all my old records? Absolutely!

But the "cutover" took weeks, not days. And, oh sorry, all my old records got lost. …

Until they finally found them. When I vented and told them that they had completely disrupted my office life, they said, "Well, we didn't exactly cover ourselves with glory."

Later, our office adopted online scheduling. This was supposed to be nimbler than old-fashioned appointment books. Except when it produced absent bookings and double-bookings and most exciting of all, when it lost schedule changes and left fully booked days when I was out of town. We longed for longhand.

Then there was automated appointment confirmation. ("In your own voice, so it won't be impersonal!") This worked well enough when it wasn't calling a day number at night or a wrong number, or putting off patients who resented being called by a machine.

Still later, we became a beta testing site for a new EMR venture. This firm also offered many fancy things and promised to save my old charts. Which they did, eventually. I decided to stick with them because my nervous system couldn't survive another cutover.

My new system could search for a patient with a single click. At first this took a while: After the click, you could get coffee, write some letters, and find the chart waiting when you got back.

Sometimes the server out in cyberspace lost contact with Houston or slowed to a crawl, at which point the EMR and Internet provider companies blamed each other.

Over the years, many such problems have been addressed and solved. The new EMR products are truly marvels of functionality: charts, scheduling, appointment confirmation, prescription writing, and heaven knows what else.

Now that the bugs have been extracted, you should look into them. Oh, and you're welcome.

My pioneering experiences with another technological wonder, the laser, were similarly successful.

The first lasers I leased in 1993 cost upward of $100,000. Could they remove tattoos? Completely—in four to eight treatments! And so much more!

One laser stopped working in 1994. The lease guy commiserated. "Some people are suing the company," he said. "They claim these lasers are nothing but giant doorstops." Indeed—giant, costly doorstops with multiyear leases.

Hair removal lasers came out in 1997. The first ones shot a 3-mm spot at the rate of two pulses every 3 seconds. Doing a back took a day or two.

And there was the little matter of heat. The hair laser produced so much of it that my landlord threatened to throw me out for destroying his HVAC system.

The laser salesman offered to buy me a room air conditioner. Would that work? He didn't know. The president of the laser company didn't know either.

This laser broke down repeatedly. So did the vascular laser.

By the time technicians came to fix them, disgruntled patients had been canceled or sent home. Revenues plummeted, but lease payments came like clockwork.

Now, of course, it's much different. Lasers are smaller, cheaper, more versatile, and far more reliable. Also, they've been around long enough for both doctors and patients to have a more realistic sense of what to expect of them. This makes for fewer service calls and fewer dissatisfied patients.

New technology can be seductive. The next time an enthusiastic salesperson stops by to tout the latest and greatest and tells you that the new product will save enough staff time to "pay for itself in 18 months" or that this new machine "will take just two treatments a month to cover your lease!" run like mad to the nearest exam room and lock the door.

Then ask yourself whether you're sure this new techno-marvel is really ready for prime time or whether you'd like to wait to let other people do the early adopting so that you can climb aboard when the innovation really does what it's supposed to—and is lots cheaper besides.

Now that the Feds are pushing them, there's a lot of buzz about electronic medical records, which most physicians have not yet implemented. I put in computerized patient records in 1989. Bully for me.

Because I'm neither technological nor gadgety, I think I did it to save space and filing time and avoid lost records. The space saving was nice, but I didn't know yet that computers lose records, too.

The computer firm I dealt with was a one-man show, so a few years later, I decided to advance to a larger operation that promised to do niftier things. Could they save all my old records? Absolutely!

But the "cutover" took weeks, not days. And, oh sorry, all my old records got lost. …

Until they finally found them. When I vented and told them that they had completely disrupted my office life, they said, "Well, we didn't exactly cover ourselves with glory."

Later, our office adopted online scheduling. This was supposed to be nimbler than old-fashioned appointment books. Except when it produced absent bookings and double-bookings and most exciting of all, when it lost schedule changes and left fully booked days when I was out of town. We longed for longhand.

Then there was automated appointment confirmation. ("In your own voice, so it won't be impersonal!") This worked well enough when it wasn't calling a day number at night or a wrong number, or putting off patients who resented being called by a machine.

Still later, we became a beta testing site for a new EMR venture. This firm also offered many fancy things and promised to save my old charts. Which they did, eventually. I decided to stick with them because my nervous system couldn't survive another cutover.

My new system could search for a patient with a single click. At first this took a while: After the click, you could get coffee, write some letters, and find the chart waiting when you got back.

Sometimes the server out in cyberspace lost contact with Houston or slowed to a crawl, at which point the EMR and Internet provider companies blamed each other.

Over the years, many such problems have been addressed and solved. The new EMR products are truly marvels of functionality: charts, scheduling, appointment confirmation, prescription writing, and heaven knows what else.

Now that the bugs have been extracted, you should look into them. Oh, and you're welcome.

My pioneering experiences with another technological wonder, the laser, were similarly successful.

The first lasers I leased in 1993 cost upward of $100,000. Could they remove tattoos? Completely—in four to eight treatments! And so much more!

One laser stopped working in 1994. The lease guy commiserated. "Some people are suing the company," he said. "They claim these lasers are nothing but giant doorstops." Indeed—giant, costly doorstops with multiyear leases.

Hair removal lasers came out in 1997. The first ones shot a 3-mm spot at the rate of two pulses every 3 seconds. Doing a back took a day or two.

And there was the little matter of heat. The hair laser produced so much of it that my landlord threatened to throw me out for destroying his HVAC system.

The laser salesman offered to buy me a room air conditioner. Would that work? He didn't know. The president of the laser company didn't know either.

This laser broke down repeatedly. So did the vascular laser.

By the time technicians came to fix them, disgruntled patients had been canceled or sent home. Revenues plummeted, but lease payments came like clockwork.

Now, of course, it's much different. Lasers are smaller, cheaper, more versatile, and far more reliable. Also, they've been around long enough for both doctors and patients to have a more realistic sense of what to expect of them. This makes for fewer service calls and fewer dissatisfied patients.

New technology can be seductive. The next time an enthusiastic salesperson stops by to tout the latest and greatest and tells you that the new product will save enough staff time to "pay for itself in 18 months" or that this new machine "will take just two treatments a month to cover your lease!" run like mad to the nearest exam room and lock the door.

Then ask yourself whether you're sure this new techno-marvel is really ready for prime time or whether you'd like to wait to let other people do the early adopting so that you can climb aboard when the innovation really does what it's supposed to—and is lots cheaper besides.

Now that the Feds are pushing them, there's a lot of buzz about electronic medical records, which most physicians have not yet implemented. I put in computerized patient records in 1989. Bully for me.

Because I'm neither technological nor gadgety, I think I did it to save space and filing time and avoid lost records. The space saving was nice, but I didn't know yet that computers lose records, too.

The computer firm I dealt with was a one-man show, so a few years later, I decided to advance to a larger operation that promised to do niftier things. Could they save all my old records? Absolutely!

But the "cutover" took weeks, not days. And, oh sorry, all my old records got lost. …

Until they finally found them. When I vented and told them that they had completely disrupted my office life, they said, "Well, we didn't exactly cover ourselves with glory."

Later, our office adopted online scheduling. This was supposed to be nimbler than old-fashioned appointment books. Except when it produced absent bookings and double-bookings and most exciting of all, when it lost schedule changes and left fully booked days when I was out of town. We longed for longhand.

Then there was automated appointment confirmation. ("In your own voice, so it won't be impersonal!") This worked well enough when it wasn't calling a day number at night or a wrong number, or putting off patients who resented being called by a machine.

Still later, we became a beta testing site for a new EMR venture. This firm also offered many fancy things and promised to save my old charts. Which they did, eventually. I decided to stick with them because my nervous system couldn't survive another cutover.

My new system could search for a patient with a single click. At first this took a while: After the click, you could get coffee, write some letters, and find the chart waiting when you got back.

Sometimes the server out in cyberspace lost contact with Houston or slowed to a crawl, at which point the EMR and Internet provider companies blamed each other.

Over the years, many such problems have been addressed and solved. The new EMR products are truly marvels of functionality: charts, scheduling, appointment confirmation, prescription writing, and heaven knows what else.

Now that the bugs have been extracted, you should look into them. Oh, and you're welcome.

My pioneering experiences with another technological wonder, the laser, were similarly successful.

The first lasers I leased in 1993 cost upward of $100,000. Could they remove tattoos? Completely—in four to eight treatments! And so much more!

One laser stopped working in 1994. The lease guy commiserated. "Some people are suing the company," he said. "They claim these lasers are nothing but giant doorstops." Indeed—giant, costly doorstops with multiyear leases.

Hair removal lasers came out in 1997. The first ones shot a 3-mm spot at the rate of two pulses every 3 seconds. Doing a back took a day or two.

And there was the little matter of heat. The hair laser produced so much of it that my landlord threatened to throw me out for destroying his HVAC system.

The laser salesman offered to buy me a room air conditioner. Would that work? He didn't know. The president of the laser company didn't know either.

This laser broke down repeatedly. So did the vascular laser.

By the time technicians came to fix them, disgruntled patients had been canceled or sent home. Revenues plummeted, but lease payments came like clockwork.

Now, of course, it's much different. Lasers are smaller, cheaper, more versatile, and far more reliable. Also, they've been around long enough for both doctors and patients to have a more realistic sense of what to expect of them. This makes for fewer service calls and fewer dissatisfied patients.

New technology can be seductive. The next time an enthusiastic salesperson stops by to tout the latest and greatest and tells you that the new product will save enough staff time to "pay for itself in 18 months" or that this new machine "will take just two treatments a month to cover your lease!" run like mad to the nearest exam room and lock the door.

Then ask yourself whether you're sure this new techno-marvel is really ready for prime time or whether you'd like to wait to let other people do the early adopting so that you can climb aboard when the innovation really does what it's supposed to—and is lots cheaper besides.

Last year, a psychiatrist consulted me as a patient and brought some promotional material about Goji juice. He said this was a marvelous nutritional supplement and suggested I sell it in the office. As a distributor, he would get a percentage.

I read through the handsome brochures he left and listened to the accompanying CD. This presented a dozen testimonials by chiropractors, physicians, and naturopaths, all ascribing an impressive array of health benefits to ingesting the juice of the Goji berry. These included a slowing of the aging process, better sleep, better sexual function and mood, improved blood pressure and sugar, more mobility and clarity of thought, and a stronger immune system with fewer colds. Other benefits included help with allergies, psoriasis, back problems, ADHD, Parkinson's disease, and restless legs syndrome.

In addition, the speakers reported cases of amazing regression of metastatic prostate and breast cancers, and disappearance of suicidal depression, sometimes in a matter of days.

It would be easy to be cynical about all this and to see it as just another link in the grand tradition of mountebanks and quacks, the greedy exploiting the gullible. Cynicism is too easy, though. It addresses only the question of why people want to sell Goji juice.

But why do people want to buy it? Even the best sales pitch won't work on people who don't believe in what you're selling. Do people really want to believe that one product can cure so many unrelated conditions, not to mention reverse mortal diseases in no time? It appears that they do.

Analysis of the Goji sales approach shows several elements:

▸ Scientific credentials. All the speakers on the CD start by announcing their field of expertise: chiropractic, medical, hard science, nutrition. Then they list their degrees: BAs in biology and nutrition, PhDs in biochemistry, MDs, diplomas in chiropractic or naturopathy. Their educational institutions range from regional schools you never heard of in the Midwest and Queensland, Australia, to esteemed institutions like Sweden's Karolinska Institute and Harvard Medical School.

▸ Scientific trappings. Several start by saying how, as men and women of science, they were skeptical at first that Goji could be really all that good. Many say they were impressed by the many articles ("more than 50") in standard medical and scientific journals they found in PubMed searches and the like. (My own PubMed search yields 57 references from Japan, most by K. Goji, others by J. Goji, and a few by their less prolific namesakes A., H., N., and T.) Several Goji testimonials include long, scientific words, like "complex polysaccharides."

▸ Ancient wisdom. Supplementing this patina of science are invocations of ancient tradition: Goji "has long been used in the Asian highlands," may explain the storied "longevity in the Far East," and reflects "thousands of years of ancient traditions of Chinese and Ayurvedic medicine."

So this is how it is: If experts with relevant-sounding credentials use plausible words, many people are prepared to at least consider that these authorities can give not just partial answers to small questions but comprehensive ones to large questions, indeed possibly to everything.

This dynamic is not limited to exotic Asian berries with silly-sounding names. Not long ago, a friend showed me a best seller by a physician on wrinkles, specifically how to prevent and get rid of them. I read it and wondered, Would anybody be prepared to accept that a single chemical, α-lipoic acid, could solve and reverse aging practically all by itself, even if several literature references say it's useful? Could anyone think that he can turn his life around in 6 weeks by eating salmon? Apparently, yes.

Closer to home, would anyone think that a cleanser or moisturizer is superior and capable of heaven knows what because a doctor's name is on the label? I guess so.

There were several comments among the Goji testimonials I found almost touching. One called Goji an "elixir for the ages." Another said he was sure that Goji would have a "greater impact on world health" than anything else he could think of. And most poignant of all, the man who said, "I have finally found the answer. The answer is Goji."

It's easy to mock this kind of thing, but the impulse underlying it is profound and pervasive. Life presents many problems, some complex and insoluble. That we all know this doesn't stop many of us from believing, or being prepared to believe, that someone, somewhere, has The Answer. Who can have anything but sympathy for those of our patients who think that, as relevant experts, we actually have it?

Last year, a psychiatrist consulted me as a patient and brought some promotional material about Goji juice. He said this was a marvelous nutritional supplement and suggested I sell it in the office. As a distributor, he would get a percentage.

I read through the handsome brochures he left and listened to the accompanying CD. This presented a dozen testimonials by chiropractors, physicians, and naturopaths, all ascribing an impressive array of health benefits to ingesting the juice of the Goji berry. These included a slowing of the aging process, better sleep, better sexual function and mood, improved blood pressure and sugar, more mobility and clarity of thought, and a stronger immune system with fewer colds. Other benefits included help with allergies, psoriasis, back problems, ADHD, Parkinson's disease, and restless legs syndrome.

In addition, the speakers reported cases of amazing regression of metastatic prostate and breast cancers, and disappearance of suicidal depression, sometimes in a matter of days.

It would be easy to be cynical about all this and to see it as just another link in the grand tradition of mountebanks and quacks, the greedy exploiting the gullible. Cynicism is too easy, though. It addresses only the question of why people want to sell Goji juice.

But why do people want to buy it? Even the best sales pitch won't work on people who don't believe in what you're selling. Do people really want to believe that one product can cure so many unrelated conditions, not to mention reverse mortal diseases in no time? It appears that they do.

Analysis of the Goji sales approach shows several elements:

▸ Scientific credentials. All the speakers on the CD start by announcing their field of expertise: chiropractic, medical, hard science, nutrition. Then they list their degrees: BAs in biology and nutrition, PhDs in biochemistry, MDs, diplomas in chiropractic or naturopathy. Their educational institutions range from regional schools you never heard of in the Midwest and Queensland, Australia, to esteemed institutions like Sweden's Karolinska Institute and Harvard Medical School.

▸ Scientific trappings. Several start by saying how, as men and women of science, they were skeptical at first that Goji could be really all that good. Many say they were impressed by the many articles ("more than 50") in standard medical and scientific journals they found in PubMed searches and the like. (My own PubMed search yields 57 references from Japan, most by K. Goji, others by J. Goji, and a few by their less prolific namesakes A., H., N., and T.) Several Goji testimonials include long, scientific words, like "complex polysaccharides."

▸ Ancient wisdom. Supplementing this patina of science are invocations of ancient tradition: Goji "has long been used in the Asian highlands," may explain the storied "longevity in the Far East," and reflects "thousands of years of ancient traditions of Chinese and Ayurvedic medicine."

So this is how it is: If experts with relevant-sounding credentials use plausible words, many people are prepared to at least consider that these authorities can give not just partial answers to small questions but comprehensive ones to large questions, indeed possibly to everything.

This dynamic is not limited to exotic Asian berries with silly-sounding names. Not long ago, a friend showed me a best seller by a physician on wrinkles, specifically how to prevent and get rid of them. I read it and wondered, Would anybody be prepared to accept that a single chemical, α-lipoic acid, could solve and reverse aging practically all by itself, even if several literature references say it's useful? Could anyone think that he can turn his life around in 6 weeks by eating salmon? Apparently, yes.

Closer to home, would anyone think that a cleanser or moisturizer is superior and capable of heaven knows what because a doctor's name is on the label? I guess so.

There were several comments among the Goji testimonials I found almost touching. One called Goji an "elixir for the ages." Another said he was sure that Goji would have a "greater impact on world health" than anything else he could think of. And most poignant of all, the man who said, "I have finally found the answer. The answer is Goji."

It's easy to mock this kind of thing, but the impulse underlying it is profound and pervasive. Life presents many problems, some complex and insoluble. That we all know this doesn't stop many of us from believing, or being prepared to believe, that someone, somewhere, has The Answer. Who can have anything but sympathy for those of our patients who think that, as relevant experts, we actually have it?

Last year, a psychiatrist consulted me as a patient and brought some promotional material about Goji juice. He said this was a marvelous nutritional supplement and suggested I sell it in the office. As a distributor, he would get a percentage.

I read through the handsome brochures he left and listened to the accompanying CD. This presented a dozen testimonials by chiropractors, physicians, and naturopaths, all ascribing an impressive array of health benefits to ingesting the juice of the Goji berry. These included a slowing of the aging process, better sleep, better sexual function and mood, improved blood pressure and sugar, more mobility and clarity of thought, and a stronger immune system with fewer colds. Other benefits included help with allergies, psoriasis, back problems, ADHD, Parkinson's disease, and restless legs syndrome.

In addition, the speakers reported cases of amazing regression of metastatic prostate and breast cancers, and disappearance of suicidal depression, sometimes in a matter of days.

It would be easy to be cynical about all this and to see it as just another link in the grand tradition of mountebanks and quacks, the greedy exploiting the gullible. Cynicism is too easy, though. It addresses only the question of why people want to sell Goji juice.

But why do people want to buy it? Even the best sales pitch won't work on people who don't believe in what you're selling. Do people really want to believe that one product can cure so many unrelated conditions, not to mention reverse mortal diseases in no time? It appears that they do.

Analysis of the Goji sales approach shows several elements:

▸ Scientific credentials. All the speakers on the CD start by announcing their field of expertise: chiropractic, medical, hard science, nutrition. Then they list their degrees: BAs in biology and nutrition, PhDs in biochemistry, MDs, diplomas in chiropractic or naturopathy. Their educational institutions range from regional schools you never heard of in the Midwest and Queensland, Australia, to esteemed institutions like Sweden's Karolinska Institute and Harvard Medical School.

▸ Scientific trappings. Several start by saying how, as men and women of science, they were skeptical at first that Goji could be really all that good. Many say they were impressed by the many articles ("more than 50") in standard medical and scientific journals they found in PubMed searches and the like. (My own PubMed search yields 57 references from Japan, most by K. Goji, others by J. Goji, and a few by their less prolific namesakes A., H., N., and T.) Several Goji testimonials include long, scientific words, like "complex polysaccharides."

▸ Ancient wisdom. Supplementing this patina of science are invocations of ancient tradition: Goji "has long been used in the Asian highlands," may explain the storied "longevity in the Far East," and reflects "thousands of years of ancient traditions of Chinese and Ayurvedic medicine."

So this is how it is: If experts with relevant-sounding credentials use plausible words, many people are prepared to at least consider that these authorities can give not just partial answers to small questions but comprehensive ones to large questions, indeed possibly to everything.

This dynamic is not limited to exotic Asian berries with silly-sounding names. Not long ago, a friend showed me a best seller by a physician on wrinkles, specifically how to prevent and get rid of them. I read it and wondered, Would anybody be prepared to accept that a single chemical, α-lipoic acid, could solve and reverse aging practically all by itself, even if several literature references say it's useful? Could anyone think that he can turn his life around in 6 weeks by eating salmon? Apparently, yes.

Closer to home, would anyone think that a cleanser or moisturizer is superior and capable of heaven knows what because a doctor's name is on the label? I guess so.

There were several comments among the Goji testimonials I found almost touching. One called Goji an "elixir for the ages." Another said he was sure that Goji would have a "greater impact on world health" than anything else he could think of. And most poignant of all, the man who said, "I have finally found the answer. The answer is Goji."

It's easy to mock this kind of thing, but the impulse underlying it is profound and pervasive. Life presents many problems, some complex and insoluble. That we all know this doesn't stop many of us from believing, or being prepared to believe, that someone, somewhere, has The Answer. Who can have anything but sympathy for those of our patients who think that, as relevant experts, we actually have it?

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

High-Tech Lists

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

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

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

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

Warts Are Female, Skin Tags Are Male

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

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

I Am Not a Dermo!

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

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

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

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

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

Clinical Research

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

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

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

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

No elaboration needed.

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

High-Tech Lists

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

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

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

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

Warts Are Female, Skin Tags Are Male

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

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

I Am Not a Dermo!

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

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

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

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

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

Clinical Research

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

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

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

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

No elaboration needed.

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

High-Tech Lists

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

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

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

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

Warts Are Female, Skin Tags Are Male

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

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

I Am Not a Dermo!

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

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

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

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

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

Clinical Research

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

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

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

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

No elaboration needed.

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

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

Below is one of the responses:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Below is one of the responses:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Below is one of the responses:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cherish it. It's shrinking.

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

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cherish it. It's shrinking.

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

Good question: What was the doctor thinking?

Better question: What was the patient thinking?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cherish it. It's shrinking.

"But nobody in my family has it!"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You know the rest.

"But nobody in my family has it!"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You know the rest.

"But nobody in my family has it!"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You know the rest.

I was flattered.

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

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

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

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

OK, what's a better doctor?

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

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

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

▸ Patients say his staff is nice.

▸ She sends prompt referral letters.

▸ He'll see an emergency right away.

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

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

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

They are wildly successful. Their patients swear by them.

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

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

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

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

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

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

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

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

I was flattered.

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

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

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

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

OK, what's a better doctor?

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

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

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

▸ Patients say his staff is nice.

▸ She sends prompt referral letters.

▸ He'll see an emergency right away.

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

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

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

They are wildly successful. Their patients swear by them.

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

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

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

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

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

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

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

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

I was flattered.

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

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

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

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

OK, what's a better doctor?

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

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

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

▸ Patients say his staff is nice.

▸ She sends prompt referral letters.

▸ He'll see an emergency right away.

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

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

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

They are wildly successful. Their patients swear by them.

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

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

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

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

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

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

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

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