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As of 2020, Dr. Rockoff began writing the quarterly column "Pruritus Emeritus."
My face is all red!
My grandson is almost 3. He is, of course, very advanced in many areas, including self-awareness.
At the moment he is suffering from Fifth Disease. (See how advanced he is – he skipped right over Diseases One through Four!) Every now and then his face clouds over as he announces, to anyone and no one, “My face is all red!”
I am not worried about long-term psychic harm. A moment later his face lights up as he looks up at the sky. “It’s a helicopter!” he declares.
By the way, does his behavior remind you of anyone else you’ve met? How about all your patients with rosacea or facial keratosis pilaris who stop by the office to say, “My face is all red!” If they didn’t notice this themselves, others have been happy to help. “You’re all red!” say their family, friends, and coworkers. “Are you all right?”
What about patients like those? Would you call them vain, or cosmetically oriented?
It seems to me that the behavior of little kids – too young to elaborate their psychological musings – sheds light on the way their elders behave, or the way they will themselves when they grow up. Years ago, I was about to laser the face of a woman with an old pulsed-dye unit that left deep-purple bruises. Her job was to train monkeys for the blind. “I need makeup,” she said. “When my monkeys see red spots on my face, they get very upset and start to point at me.”
“Not just monkeys,” I replied.
To take another example, many years ago I saw a little tyke about 18 months old. His parents were concerned about a mole on his palm.
He was not happy to let me examine him, and he let me know. “It’s OK,” I said, in my most condescending, clueless adult voice. “Your Mom and Dad just asked me to check your boo-boo.”
That set him off. “No boo-boo!” he shouted. “No boo-boo!”
Well, silly me, I later realized. The tyke was right: Of course it was not a boo-boo. A boo-boo is an assault on the integrity of the body: a cut, a scrape, a burn, something new, painful, hard to look at. That is why 9.8 out of 10 people whom we freeze, burn, or puncture look the other way while we do it. It’s also why kids dial their screams down to whimpers when we hide what we froze, burned, or punctured by covering it with a Band-Aid. Now the boo-boo is out of sight.
The tyke’s mole, on the other hand, is not an insult to the body but a part of it. It’s him.
Fast forward 15 years and ask a teen with a large (but not giant) hairy congenital nevus if she wants it off. She does not. “That’s me,” she explains.
Or ask an adult with what you would think is a disfiguring facial port-wine stain what growing up with that was like. “It was fine,” they reply. “Strangers sometimes commented, but my friends knew that was just how I looked.”
Or listen to folks who want their liver spots lasered off. They point to a dozen or so, then add, “But don’t take off that one! That’s always been there. That’s just me.”
If you listen for it, you can pick up how early a lot of adult behavior starts. Little ones destined to be lifetime pickers start scraping off anything that’s raised above the skin. Teens finicky about facial moles or minute perturbations in their complexion grow into fussy adults.
We grownups learn to embroider our primal responses with words, thoughts, feeling, explanations. Kids just come out and say what they think – “My face is all red!”
Soon my grandson will have overcome his Fifth Disease without, I hope, graduating to any higher numbers. His other grandfather is a retired engineer who used to design helicopters. By next year I expect that our mutual grandson will be able to identify anything flying overhead by make and model number.
As I said, he’s very advanced.
Also cute as all get-out, (temporary) red face and all.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com
My grandson is almost 3. He is, of course, very advanced in many areas, including self-awareness.
At the moment he is suffering from Fifth Disease. (See how advanced he is – he skipped right over Diseases One through Four!) Every now and then his face clouds over as he announces, to anyone and no one, “My face is all red!”
I am not worried about long-term psychic harm. A moment later his face lights up as he looks up at the sky. “It’s a helicopter!” he declares.
By the way, does his behavior remind you of anyone else you’ve met? How about all your patients with rosacea or facial keratosis pilaris who stop by the office to say, “My face is all red!” If they didn’t notice this themselves, others have been happy to help. “You’re all red!” say their family, friends, and coworkers. “Are you all right?”
What about patients like those? Would you call them vain, or cosmetically oriented?
It seems to me that the behavior of little kids – too young to elaborate their psychological musings – sheds light on the way their elders behave, or the way they will themselves when they grow up. Years ago, I was about to laser the face of a woman with an old pulsed-dye unit that left deep-purple bruises. Her job was to train monkeys for the blind. “I need makeup,” she said. “When my monkeys see red spots on my face, they get very upset and start to point at me.”
“Not just monkeys,” I replied.
To take another example, many years ago I saw a little tyke about 18 months old. His parents were concerned about a mole on his palm.
He was not happy to let me examine him, and he let me know. “It’s OK,” I said, in my most condescending, clueless adult voice. “Your Mom and Dad just asked me to check your boo-boo.”
That set him off. “No boo-boo!” he shouted. “No boo-boo!”
Well, silly me, I later realized. The tyke was right: Of course it was not a boo-boo. A boo-boo is an assault on the integrity of the body: a cut, a scrape, a burn, something new, painful, hard to look at. That is why 9.8 out of 10 people whom we freeze, burn, or puncture look the other way while we do it. It’s also why kids dial their screams down to whimpers when we hide what we froze, burned, or punctured by covering it with a Band-Aid. Now the boo-boo is out of sight.
The tyke’s mole, on the other hand, is not an insult to the body but a part of it. It’s him.
Fast forward 15 years and ask a teen with a large (but not giant) hairy congenital nevus if she wants it off. She does not. “That’s me,” she explains.
Or ask an adult with what you would think is a disfiguring facial port-wine stain what growing up with that was like. “It was fine,” they reply. “Strangers sometimes commented, but my friends knew that was just how I looked.”
Or listen to folks who want their liver spots lasered off. They point to a dozen or so, then add, “But don’t take off that one! That’s always been there. That’s just me.”
If you listen for it, you can pick up how early a lot of adult behavior starts. Little ones destined to be lifetime pickers start scraping off anything that’s raised above the skin. Teens finicky about facial moles or minute perturbations in their complexion grow into fussy adults.
We grownups learn to embroider our primal responses with words, thoughts, feeling, explanations. Kids just come out and say what they think – “My face is all red!”
Soon my grandson will have overcome his Fifth Disease without, I hope, graduating to any higher numbers. His other grandfather is a retired engineer who used to design helicopters. By next year I expect that our mutual grandson will be able to identify anything flying overhead by make and model number.
As I said, he’s very advanced.
Also cute as all get-out, (temporary) red face and all.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com
My grandson is almost 3. He is, of course, very advanced in many areas, including self-awareness.
At the moment he is suffering from Fifth Disease. (See how advanced he is – he skipped right over Diseases One through Four!) Every now and then his face clouds over as he announces, to anyone and no one, “My face is all red!”
I am not worried about long-term psychic harm. A moment later his face lights up as he looks up at the sky. “It’s a helicopter!” he declares.
By the way, does his behavior remind you of anyone else you’ve met? How about all your patients with rosacea or facial keratosis pilaris who stop by the office to say, “My face is all red!” If they didn’t notice this themselves, others have been happy to help. “You’re all red!” say their family, friends, and coworkers. “Are you all right?”
What about patients like those? Would you call them vain, or cosmetically oriented?
It seems to me that the behavior of little kids – too young to elaborate their psychological musings – sheds light on the way their elders behave, or the way they will themselves when they grow up. Years ago, I was about to laser the face of a woman with an old pulsed-dye unit that left deep-purple bruises. Her job was to train monkeys for the blind. “I need makeup,” she said. “When my monkeys see red spots on my face, they get very upset and start to point at me.”
“Not just monkeys,” I replied.
To take another example, many years ago I saw a little tyke about 18 months old. His parents were concerned about a mole on his palm.
He was not happy to let me examine him, and he let me know. “It’s OK,” I said, in my most condescending, clueless adult voice. “Your Mom and Dad just asked me to check your boo-boo.”
That set him off. “No boo-boo!” he shouted. “No boo-boo!”
Well, silly me, I later realized. The tyke was right: Of course it was not a boo-boo. A boo-boo is an assault on the integrity of the body: a cut, a scrape, a burn, something new, painful, hard to look at. That is why 9.8 out of 10 people whom we freeze, burn, or puncture look the other way while we do it. It’s also why kids dial their screams down to whimpers when we hide what we froze, burned, or punctured by covering it with a Band-Aid. Now the boo-boo is out of sight.
The tyke’s mole, on the other hand, is not an insult to the body but a part of it. It’s him.
Fast forward 15 years and ask a teen with a large (but not giant) hairy congenital nevus if she wants it off. She does not. “That’s me,” she explains.
Or ask an adult with what you would think is a disfiguring facial port-wine stain what growing up with that was like. “It was fine,” they reply. “Strangers sometimes commented, but my friends knew that was just how I looked.”
Or listen to folks who want their liver spots lasered off. They point to a dozen or so, then add, “But don’t take off that one! That’s always been there. That’s just me.”
If you listen for it, you can pick up how early a lot of adult behavior starts. Little ones destined to be lifetime pickers start scraping off anything that’s raised above the skin. Teens finicky about facial moles or minute perturbations in their complexion grow into fussy adults.
We grownups learn to embroider our primal responses with words, thoughts, feeling, explanations. Kids just come out and say what they think – “My face is all red!”
Soon my grandson will have overcome his Fifth Disease without, I hope, graduating to any higher numbers. His other grandfather is a retired engineer who used to design helicopters. By next year I expect that our mutual grandson will be able to identify anything flying overhead by make and model number.
As I said, he’s very advanced.
Also cute as all get-out, (temporary) red face and all.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com
Unforgiveness
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
The dermatologic tourist
I’m not much of a traveler. I like to see the world through the adventures of my patients.
This is especially nice in the winter, such as during school vacation week. Within the past 24 hours, I’ve gotten messages from patients in Hawaii, Arizona, and Orlando.
Writing from Hawaii, Melvin showed me a photo of a small white spot that appeared on the outer aspect of his arm. I couldn’t make much of it except to tell him that it doesn’t look like anything that warrants a 9-hour flight to show it to me, at least not until he gets back to town.
Finally, Svetlana forwarded a photograph of a rash on her foot that she said had “just come yesterday.” This was the nicest case of cutaneous larva migrans that I’ve seen in quite some time, although I am fairly sure it has been there for more than a day. I tried not to sound too excited about her diagnosis, of course (“You’ve got the coolest parasite!”), and just suggested that she come in to see me on her return next week.
North, South, West. I’ve been all over, without leaving the chair facing my computer screen. (Nobody seems to have gotten a volcanic eruption in Iceland this year.) All this with no packing, no waiting in airports, no TSA lines. Who says traveling can’t be a pleasure?
Practice dermatology – see the world!
* * * * * * * * * * * * * * * * * * * * * * *
Brian was delighted. The fungal infection on his calf, treated for weeks with a topical steroid that had produced only intolerable itch, was subsiding nicely with oral terbinafine and topical ketoconazole.
“Can I drink when I take this medicine?” he asked. “The Internet says I shouldn’t.”
“It’s only another week, Brian,” I said. “Best to hold off ‘till then.”
“Because I really needed a drink last week,” he said.
“Why was that?”
“I was on a vacation with my father.”
“I see.”
“It was my father and his 70-year-old girlfriend.”
“Oh.”
“We were at a nudist colony.”
“You know, Brian,” I said. “Just hearing about that makes me want a drink myself.”
Practice can take you places you never went, places you’ll never get to, places you never want to get to.
* * * * * * * * * * * * * * * * * * * * * * *
Although I have patients fill out the usual consent form on oral isotretinoin, on which they promise to contact me if they become depressed, I rarely find anyone who does. Instead, people tend to become rather happy once their acne improves.
Since I’m not a psychiatrist, I try to do an amateur job of assessing mood when patients come in for their monthly follow-up. I pass on my technique for any of you might find it useful.
“Hello, Peter, are you having any problems?”
“No.”
“Do you get headaches?”
“No.”
“Nosebleeds?”
“No.”
“Any aches and pains in your muscles?”
“No.”
“Are you depressed?”
“No.”
“Are you always this negative?”
If the patient smiles while saying, “No,” you’re in good shape. If not, consider suggesting a therapist.
Better still, send the patient to the Caribbean. Then propose that you go come along yourself as a consultant, just to keep an eye on things.
And bring sunscreen. For the two of you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
I’m not much of a traveler. I like to see the world through the adventures of my patients.
This is especially nice in the winter, such as during school vacation week. Within the past 24 hours, I’ve gotten messages from patients in Hawaii, Arizona, and Orlando.
Writing from Hawaii, Melvin showed me a photo of a small white spot that appeared on the outer aspect of his arm. I couldn’t make much of it except to tell him that it doesn’t look like anything that warrants a 9-hour flight to show it to me, at least not until he gets back to town.
Finally, Svetlana forwarded a photograph of a rash on her foot that she said had “just come yesterday.” This was the nicest case of cutaneous larva migrans that I’ve seen in quite some time, although I am fairly sure it has been there for more than a day. I tried not to sound too excited about her diagnosis, of course (“You’ve got the coolest parasite!”), and just suggested that she come in to see me on her return next week.
North, South, West. I’ve been all over, without leaving the chair facing my computer screen. (Nobody seems to have gotten a volcanic eruption in Iceland this year.) All this with no packing, no waiting in airports, no TSA lines. Who says traveling can’t be a pleasure?
Practice dermatology – see the world!
* * * * * * * * * * * * * * * * * * * * * * *
Brian was delighted. The fungal infection on his calf, treated for weeks with a topical steroid that had produced only intolerable itch, was subsiding nicely with oral terbinafine and topical ketoconazole.
“Can I drink when I take this medicine?” he asked. “The Internet says I shouldn’t.”
“It’s only another week, Brian,” I said. “Best to hold off ‘till then.”
“Because I really needed a drink last week,” he said.
“Why was that?”
“I was on a vacation with my father.”
“I see.”
“It was my father and his 70-year-old girlfriend.”
“Oh.”
“We were at a nudist colony.”
“You know, Brian,” I said. “Just hearing about that makes me want a drink myself.”
Practice can take you places you never went, places you’ll never get to, places you never want to get to.
* * * * * * * * * * * * * * * * * * * * * * *
Although I have patients fill out the usual consent form on oral isotretinoin, on which they promise to contact me if they become depressed, I rarely find anyone who does. Instead, people tend to become rather happy once their acne improves.
Since I’m not a psychiatrist, I try to do an amateur job of assessing mood when patients come in for their monthly follow-up. I pass on my technique for any of you might find it useful.
“Hello, Peter, are you having any problems?”
“No.”
“Do you get headaches?”
“No.”
“Nosebleeds?”
“No.”
“Any aches and pains in your muscles?”
“No.”
“Are you depressed?”
“No.”
“Are you always this negative?”
If the patient smiles while saying, “No,” you’re in good shape. If not, consider suggesting a therapist.
Better still, send the patient to the Caribbean. Then propose that you go come along yourself as a consultant, just to keep an eye on things.
And bring sunscreen. For the two of you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
I’m not much of a traveler. I like to see the world through the adventures of my patients.
This is especially nice in the winter, such as during school vacation week. Within the past 24 hours, I’ve gotten messages from patients in Hawaii, Arizona, and Orlando.
Writing from Hawaii, Melvin showed me a photo of a small white spot that appeared on the outer aspect of his arm. I couldn’t make much of it except to tell him that it doesn’t look like anything that warrants a 9-hour flight to show it to me, at least not until he gets back to town.
Finally, Svetlana forwarded a photograph of a rash on her foot that she said had “just come yesterday.” This was the nicest case of cutaneous larva migrans that I’ve seen in quite some time, although I am fairly sure it has been there for more than a day. I tried not to sound too excited about her diagnosis, of course (“You’ve got the coolest parasite!”), and just suggested that she come in to see me on her return next week.
North, South, West. I’ve been all over, without leaving the chair facing my computer screen. (Nobody seems to have gotten a volcanic eruption in Iceland this year.) All this with no packing, no waiting in airports, no TSA lines. Who says traveling can’t be a pleasure?
Practice dermatology – see the world!
* * * * * * * * * * * * * * * * * * * * * * *
Brian was delighted. The fungal infection on his calf, treated for weeks with a topical steroid that had produced only intolerable itch, was subsiding nicely with oral terbinafine and topical ketoconazole.
“Can I drink when I take this medicine?” he asked. “The Internet says I shouldn’t.”
“It’s only another week, Brian,” I said. “Best to hold off ‘till then.”
“Because I really needed a drink last week,” he said.
“Why was that?”
“I was on a vacation with my father.”
“I see.”
“It was my father and his 70-year-old girlfriend.”
“Oh.”
“We were at a nudist colony.”
“You know, Brian,” I said. “Just hearing about that makes me want a drink myself.”
Practice can take you places you never went, places you’ll never get to, places you never want to get to.
* * * * * * * * * * * * * * * * * * * * * * *
Although I have patients fill out the usual consent form on oral isotretinoin, on which they promise to contact me if they become depressed, I rarely find anyone who does. Instead, people tend to become rather happy once their acne improves.
Since I’m not a psychiatrist, I try to do an amateur job of assessing mood when patients come in for their monthly follow-up. I pass on my technique for any of you might find it useful.
“Hello, Peter, are you having any problems?”
“No.”
“Do you get headaches?”
“No.”
“Nosebleeds?”
“No.”
“Any aches and pains in your muscles?”
“No.”
“Are you depressed?”
“No.”
“Are you always this negative?”
If the patient smiles while saying, “No,” you’re in good shape. If not, consider suggesting a therapist.
Better still, send the patient to the Caribbean. Then propose that you go come along yourself as a consultant, just to keep an eye on things.
And bring sunscreen. For the two of you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
When the iPad is on the other foot
Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.
“How do you spell that again?” he wanted to know.
I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.
“Wait, you say it isn’t fungal?”
“No ...”
Typing. “And you don’t know the cause?”
“No, the medical term for that is ‘idiopathic’ ...”
“Wait, how do you spell that?”
I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”
More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”
“A cream. Betamethasone dipropionate.”
“Hold on! How do you spell that?”
I spelled it out, along with “augmented” and “0.05%.”
The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)
When my student and I left the room, I took him aside.
“Did you see anything unusual about how that visit went?” I asked.
When he looked blank, I explained: “The patient didn’t look me in the eye once.”
Yes, come to think of it, the student had noticed that.
“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.
“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.
“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.
“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”
He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.
No need to spell this out for the younger generation, literally or otherwise.
Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:
Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:
“The patient is a flight attendant for Diflucan Airlines.”
Check them out. Their restrooms are so clean you can go barefoot.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.
“How do you spell that again?” he wanted to know.
I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.
“Wait, you say it isn’t fungal?”
“No ...”
Typing. “And you don’t know the cause?”
“No, the medical term for that is ‘idiopathic’ ...”
“Wait, how do you spell that?”
I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”
More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”
“A cream. Betamethasone dipropionate.”
“Hold on! How do you spell that?”
I spelled it out, along with “augmented” and “0.05%.”
The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)
When my student and I left the room, I took him aside.
“Did you see anything unusual about how that visit went?” I asked.
When he looked blank, I explained: “The patient didn’t look me in the eye once.”
Yes, come to think of it, the student had noticed that.
“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.
“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.
“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.
“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”
He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.
No need to spell this out for the younger generation, literally or otherwise.
Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:
Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:
“The patient is a flight attendant for Diflucan Airlines.”
Check them out. Their restrooms are so clean you can go barefoot.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.
“How do you spell that again?” he wanted to know.
I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.
“Wait, you say it isn’t fungal?”
“No ...”
Typing. “And you don’t know the cause?”
“No, the medical term for that is ‘idiopathic’ ...”
“Wait, how do you spell that?”
I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”
More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”
“A cream. Betamethasone dipropionate.”
“Hold on! How do you spell that?”
I spelled it out, along with “augmented” and “0.05%.”
The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)
When my student and I left the room, I took him aside.
“Did you see anything unusual about how that visit went?” I asked.
When he looked blank, I explained: “The patient didn’t look me in the eye once.”
Yes, come to think of it, the student had noticed that.
“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.
“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.
“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.
“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”
He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.
No need to spell this out for the younger generation, literally or otherwise.
Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:
Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:
“The patient is a flight attendant for Diflucan Airlines.”
Check them out. Their restrooms are so clean you can go barefoot.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
But you told me...
“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”
I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.
In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.
No, I didn’t.
I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?
That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.
Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.
Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”
Nope, not even close.
What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?
The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.
“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”
Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.
No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”
Philip nods. I think he understands. But I thought so last time too, didn’t I?
I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”
No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.
Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.
I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.
I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”
That was clear. I think.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”
I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.
In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.
No, I didn’t.
I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?
That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.
Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.
Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”
Nope, not even close.
What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?
The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.
“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”
Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.
No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”
Philip nods. I think he understands. But I thought so last time too, didn’t I?
I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”
No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.
Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.
I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.
I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”
That was clear. I think.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”
I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.
In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.
No, I didn’t.
I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?
That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.
Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.
Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”
Nope, not even close.
What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?
The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.
“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”
Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.
No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”
Philip nods. I think he understands. But I thought so last time too, didn’t I?
I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”
No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.
Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.
I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.
I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”
That was clear. I think.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
It’s working! (No it’s not! Yes it is!)
A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com .
A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com .
A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com .
The $400 generic
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
A dermatologic little list
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Miscellany
Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:
Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”
Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...
You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”
“Where do you buy an analyst couch?” I asked.
“Analyticcouch.com,” she explained. “Available in a variety of colors.”
What a country!
No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”
The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.
“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”
That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.
“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”
There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.
Then the other day Marcy surprised me with this:
“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”
A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...
You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.
My jaw dropped, but no words came out.
“It’s that sign you put up,” he said, “right on the exam room door.”
As I don’t usually read my own signs, I turned to look. The sign read:
“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”
“It says, ‘No-Showed,” I said. Not ‘No Showers.”
I resisted the urge to refer him to an optometrist.
This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”
“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”
“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.
“Upstairs,” I said. “Seventh floor.”
Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”
“But it has to be a whole day ...”
“Fifteen hours,” he said. “I’ll give you 15 hours.”
“But we need ...”
“Eighteen hours. OK?”
“Well, not really. You see, the test has to be a whole day ...”
“All right, 21 hours. That’s my best offer.”
Maybe if I could get him to spend the day in that Egyptian bathroom ...
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book, “Act Like a Doctor, Think Like a Patient,” is now available on amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:
Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”
Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...
You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”
“Where do you buy an analyst couch?” I asked.
“Analyticcouch.com,” she explained. “Available in a variety of colors.”
What a country!
No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”
The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.
“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”
That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.
“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”
There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.
Then the other day Marcy surprised me with this:
“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”
A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...
You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.
My jaw dropped, but no words came out.
“It’s that sign you put up,” he said, “right on the exam room door.”
As I don’t usually read my own signs, I turned to look. The sign read:
“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”
“It says, ‘No-Showed,” I said. Not ‘No Showers.”
I resisted the urge to refer him to an optometrist.
This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”
“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”
“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.
“Upstairs,” I said. “Seventh floor.”
Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”
“But it has to be a whole day ...”
“Fifteen hours,” he said. “I’ll give you 15 hours.”
“But we need ...”
“Eighteen hours. OK?”
“Well, not really. You see, the test has to be a whole day ...”
“All right, 21 hours. That’s my best offer.”
Maybe if I could get him to spend the day in that Egyptian bathroom ...
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book, “Act Like a Doctor, Think Like a Patient,” is now available on amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:
Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”
Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...
You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”
“Where do you buy an analyst couch?” I asked.
“Analyticcouch.com,” she explained. “Available in a variety of colors.”
What a country!
No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”
The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.
“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”
That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.
“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”
There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.
Then the other day Marcy surprised me with this:
“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”
A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...
You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.
My jaw dropped, but no words came out.
“It’s that sign you put up,” he said, “right on the exam room door.”
As I don’t usually read my own signs, I turned to look. The sign read:
“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”
“It says, ‘No-Showed,” I said. Not ‘No Showers.”
I resisted the urge to refer him to an optometrist.
This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”
“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”
“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.
“Upstairs,” I said. “Seventh floor.”
Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”
“But it has to be a whole day ...”
“Fifteen hours,” he said. “I’ll give you 15 hours.”
“But we need ...”
“Eighteen hours. OK?”
“Well, not really. You see, the test has to be a whole day ...”
“All right, 21 hours. That’s my best offer.”
Maybe if I could get him to spend the day in that Egyptian bathroom ...
Dr. Rockoff practices dermatology in Brookline, Mass, and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book, “Act Like a Doctor, Think Like a Patient,” is now available on amazon.com and barnesandnoble.com. This is his second book. Write to him at dermnews@frontlinemedcom.com.
Loss of autonomy
At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”
Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.
A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”
“Academics used to be autonomous,” he said. “No more.”
Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”
New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?
Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.
“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”
“What will you do instead?” I asked him.
“Something with dogs,” he said.
And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.
An internist told me how things are in her new dispensation.
“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.
“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”
Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.
Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.
To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.
Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.
To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.
At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”
Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.
A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”
“Academics used to be autonomous,” he said. “No more.”
Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”
New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?
Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.
“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”
“What will you do instead?” I asked him.
“Something with dogs,” he said.
And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.
An internist told me how things are in her new dispensation.
“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.
“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”
Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.
Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.
To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.
Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.
To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.
At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”
Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.
A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”
“Academics used to be autonomous,” he said. “No more.”
Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”
New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?
Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.
“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”
“What will you do instead?” I asked him.
“Something with dogs,” he said.
And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.
An internist told me how things are in her new dispensation.
“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.
“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”
Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.
Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.
To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.
Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.
To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.
