Under My Skin

Two disturbing patients came by last week.

The first was a frail old man. His daughter brought him. She said he’d been living in Florida and “shown up” on her doorstep.

As a dermatologist, I’m not often thrown by what I see, but this unfortunate man’s face was hard to look at, with a gaping hole where his left nasolabial fold should have been.

How long had the cancer been there to gouge that hole? How could he neglect it so long? What kind of relationship (or nonrelationship) with his child did it take for this to happen?

I didn’t pursue these questions. Instead, I referred him and his daughter to a skin oncology center where, I hoped, therapy could manage a situation whose severity could surely have been prevented.

Two days later, a Russian woman came in. Remarkably hale at the age of 95 years, she spoke no English. The man who accompanied her, a relative youngster in his mid-70’s, was not a relative, just a stranger who took pity on a fellow visitor to a Russian senior center. “She has two sons,” he explained, “but they live in Minnesota and Texas.”

Her problem was also a basal cell, but this one was on the back of her right ear, large but manageable. I arranged to remove the lesion and offered to speak with her sons. Neither ever called.

Disease is a physical problem in a social context. Patients often present with problems they ignored until other people insisted they take care of them. Parents bring their children. Women drag their husbands. Patients tolerate their itch until their coworkers get annoyed “at seeing me scratch like a monkey.” In situations like these – you can come up with many others – the problem is not just with the patients, but with the people in their vicinity. Sometimes there are people in patients’ lives who notice and care, who demand, “Have that looked at!” But what if nobody cares? Or what if there is no one around at all?

Factors like mental, family, and social dysfunction often underlie whether and to what extent the diseases we diagnose get treated. As practicing physicians, we have little control over such factors. We just try to manage what presents in our offices.

So we make assumptions– that patients can afford to see us, that they have the common sense to come, that they have family or friends who encourage them to come and make doing that possible.

In cases like the ones I’ve just described, these assumptions were wrong. The old man from Florida probably rarely left his apartment, and when he did people just looked away in disgust. He wasn’t their problem. In both cases family was nowhere to be found. How many such lonely and neglected people are there with no support systems, who don’t show up on our office doorstep until it is hard or impossible to take care of them?

I sometimes think back to a case that has haunted me since my early years, when I worked in several Boston-area health centers and sometimes made house calls in gritty neighborhoods. One day I was called to see a patient on the first floor of a rundown example of one of Boston’s wood-frame triple-deckers.

The front door was open. No one was around. I wandered past the parlor into a bedroom. There lay the patient: A woman in late middle age, lying on her back in a dirty nightgown, staring at the ceiling. That image has haunted me for 30 years.

I no longer remember what her skin problem was, just the pitiful sight of her and all the questions it raised: Where was everybody? Who looked after this woman? Who cooked for her, shopped for her? If I prescribed something, who would see that she got it and used it?

I didn’t know. Even if I did, there was nothing I could do about it. Doctors in practice can’t make families stay together, or weave a social safety net that neglected people don’t slip through.

When something lies beyond the scope of what you take to be your responsibility, it’s easier to look away. Now and then a neglected patient forces us to face our own limitations and pay attention to what we have been not looking at.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Two disturbing patients came by last week.

The first was a frail old man. His daughter brought him. She said he’d been living in Florida and “shown up” on her doorstep.

As a dermatologist, I’m not often thrown by what I see, but this unfortunate man’s face was hard to look at, with a gaping hole where his left nasolabial fold should have been.

How long had the cancer been there to gouge that hole? How could he neglect it so long? What kind of relationship (or nonrelationship) with his child did it take for this to happen?

I didn’t pursue these questions. Instead, I referred him and his daughter to a skin oncology center where, I hoped, therapy could manage a situation whose severity could surely have been prevented.

Two days later, a Russian woman came in. Remarkably hale at the age of 95 years, she spoke no English. The man who accompanied her, a relative youngster in his mid-70’s, was not a relative, just a stranger who took pity on a fellow visitor to a Russian senior center. “She has two sons,” he explained, “but they live in Minnesota and Texas.”

Her problem was also a basal cell, but this one was on the back of her right ear, large but manageable. I arranged to remove the lesion and offered to speak with her sons. Neither ever called.

Disease is a physical problem in a social context. Patients often present with problems they ignored until other people insisted they take care of them. Parents bring their children. Women drag their husbands. Patients tolerate their itch until their coworkers get annoyed “at seeing me scratch like a monkey.” In situations like these – you can come up with many others – the problem is not just with the patients, but with the people in their vicinity. Sometimes there are people in patients’ lives who notice and care, who demand, “Have that looked at!” But what if nobody cares? Or what if there is no one around at all?

Factors like mental, family, and social dysfunction often underlie whether and to what extent the diseases we diagnose get treated. As practicing physicians, we have little control over such factors. We just try to manage what presents in our offices.

So we make assumptions– that patients can afford to see us, that they have the common sense to come, that they have family or friends who encourage them to come and make doing that possible.

In cases like the ones I’ve just described, these assumptions were wrong. The old man from Florida probably rarely left his apartment, and when he did people just looked away in disgust. He wasn’t their problem. In both cases family was nowhere to be found. How many such lonely and neglected people are there with no support systems, who don’t show up on our office doorstep until it is hard or impossible to take care of them?

I sometimes think back to a case that has haunted me since my early years, when I worked in several Boston-area health centers and sometimes made house calls in gritty neighborhoods. One day I was called to see a patient on the first floor of a rundown example of one of Boston’s wood-frame triple-deckers.

The front door was open. No one was around. I wandered past the parlor into a bedroom. There lay the patient: A woman in late middle age, lying on her back in a dirty nightgown, staring at the ceiling. That image has haunted me for 30 years.

I no longer remember what her skin problem was, just the pitiful sight of her and all the questions it raised: Where was everybody? Who looked after this woman? Who cooked for her, shopped for her? If I prescribed something, who would see that she got it and used it?

I didn’t know. Even if I did, there was nothing I could do about it. Doctors in practice can’t make families stay together, or weave a social safety net that neglected people don’t slip through.

When something lies beyond the scope of what you take to be your responsibility, it’s easier to look away. Now and then a neglected patient forces us to face our own limitations and pay attention to what we have been not looking at.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Two disturbing patients came by last week.

The first was a frail old man. His daughter brought him. She said he’d been living in Florida and “shown up” on her doorstep.

As a dermatologist, I’m not often thrown by what I see, but this unfortunate man’s face was hard to look at, with a gaping hole where his left nasolabial fold should have been.

How long had the cancer been there to gouge that hole? How could he neglect it so long? What kind of relationship (or nonrelationship) with his child did it take for this to happen?

I didn’t pursue these questions. Instead, I referred him and his daughter to a skin oncology center where, I hoped, therapy could manage a situation whose severity could surely have been prevented.

Two days later, a Russian woman came in. Remarkably hale at the age of 95 years, she spoke no English. The man who accompanied her, a relative youngster in his mid-70’s, was not a relative, just a stranger who took pity on a fellow visitor to a Russian senior center. “She has two sons,” he explained, “but they live in Minnesota and Texas.”

Her problem was also a basal cell, but this one was on the back of her right ear, large but manageable. I arranged to remove the lesion and offered to speak with her sons. Neither ever called.

Disease is a physical problem in a social context. Patients often present with problems they ignored until other people insisted they take care of them. Parents bring their children. Women drag their husbands. Patients tolerate their itch until their coworkers get annoyed “at seeing me scratch like a monkey.” In situations like these – you can come up with many others – the problem is not just with the patients, but with the people in their vicinity. Sometimes there are people in patients’ lives who notice and care, who demand, “Have that looked at!” But what if nobody cares? Or what if there is no one around at all?

Factors like mental, family, and social dysfunction often underlie whether and to what extent the diseases we diagnose get treated. As practicing physicians, we have little control over such factors. We just try to manage what presents in our offices.

So we make assumptions– that patients can afford to see us, that they have the common sense to come, that they have family or friends who encourage them to come and make doing that possible.

In cases like the ones I’ve just described, these assumptions were wrong. The old man from Florida probably rarely left his apartment, and when he did people just looked away in disgust. He wasn’t their problem. In both cases family was nowhere to be found. How many such lonely and neglected people are there with no support systems, who don’t show up on our office doorstep until it is hard or impossible to take care of them?

I sometimes think back to a case that has haunted me since my early years, when I worked in several Boston-area health centers and sometimes made house calls in gritty neighborhoods. One day I was called to see a patient on the first floor of a rundown example of one of Boston’s wood-frame triple-deckers.

The front door was open. No one was around. I wandered past the parlor into a bedroom. There lay the patient: A woman in late middle age, lying on her back in a dirty nightgown, staring at the ceiling. That image has haunted me for 30 years.

I no longer remember what her skin problem was, just the pitiful sight of her and all the questions it raised: Where was everybody? Who looked after this woman? Who cooked for her, shopped for her? If I prescribed something, who would see that she got it and used it?

I didn’t know. Even if I did, there was nothing I could do about it. Doctors in practice can’t make families stay together, or weave a social safety net that neglected people don’t slip through.

When something lies beyond the scope of what you take to be your responsibility, it’s easier to look away. Now and then a neglected patient forces us to face our own limitations and pay attention to what we have been not looking at.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

I got my Medicare card 2 years ago (guess how old I am?). At this year’s physical exam (my first exam under new rules that let Medicare pay for routine annual physicals), the clerk asked me to fill out the “Health-Risk Assessment” form my PCP would need for billing.

This form had two pages. Page 1 listed 26 questions, each to be answered by checking off one of the following six choices: Never, Sometimes, Seldom, Often, Always, and Not Applicable.

Right away you see a problem. If this were an SAT test, say, where I actually cared whether or not I passed, I would summon a proctor and demand to know the difference between “Sometimes” and “Seldom,” or whether “Always” includes when I’m asleep, intoxicated, or filling out forms.

I will not burden you with all 26 questions. Instead, I’ll present several (these are the actual questions, folks, word for word), along with the answers I would have given had I not been hamstrung by the Six Categories. Each question is headed, “In the past 4 weeks.”

Q: How much have you felt little interest or pleasure?

A: I have very much felt little interest, and very little felt much interest. On the other hand, I have much interest in the little pleasure I have felt, and much pleasure in the little interest I have had.

Q: Has your physical and emotional health limited your social activities with family, friends, neighbors or groups?

A: No, but lack of money has.

Q: Have you needed help preparing your own meals?

A: Yes, ever since I got married, but that was more than 4 weeks ago. I can still make omelets, though.

Q: Are you having difficulties driving your car?

A: Do you know Boston drivers?

Q: Have you needed help managing your finances?

A: Not since 2008, and then it was my broker who needed the help.

Q: Have you needed help with household chores?

A: Never do ‘em.

Q: Do you have concerns about your memory?

A: What?

Q: DO YOU HAVE CONCERNS ABOUT YOUR MEMORY?

A: Not so much about what I can’t remember, mostly about what I can.

Q: Do any of your friends/family have concerns about your memory?

A: No, other than whether I’ll remember them in my will.

Q: Have you had sexual problems?

A: Too much. Too little. I forget. But that’s just the last 4 weeks. Six weeks ago was amazing.

Q: Have problems using a telephone?

A: Damn right. Cellular connectivity around here stinks.

Q: Do you exercise for about 20 minutes, 3 or more days a week?

A: I always exercise sometimes. I sometimes exercise always. Could you repeat the question?

Q: Does your home have throw rugs?

A: It has rugs, but nobody throws them.

Q: Does your home have poor lighting?

A: Ever since they outlawed incandescents. When I flip the switch, they’re fully lit by the time I finish breakfast, but by then it’s time to turn them off and go to work.

Q: During the past 4 weeks, how have things been going for you?

A: The Red Sox are doing lousy. Did you have to ask?

The form ends with thanks for taking the time to fill out the form and concludes with this cheery note: “Your responses will help you receive the best health and health care possible.”

When my physical was done, my doctor found the form in my paper pile. “I see you filled it out,” she said.

“By the way,” I asked her. ‘”What do you do with these forms?”

“Absolutely nothing,” she said.

“You don’t have to submit them for tabulation or something?”

“No,” she said.

If you’re not on Medicare yet, this is what you have to look forward to. Always.

Sometimes.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

sknews@frontlinemedcom.com

I got my Medicare card 2 years ago (guess how old I am?). At this year’s physical exam (my first exam under new rules that let Medicare pay for routine annual physicals), the clerk asked me to fill out the “Health-Risk Assessment” form my PCP would need for billing.

This form had two pages. Page 1 listed 26 questions, each to be answered by checking off one of the following six choices: Never, Sometimes, Seldom, Often, Always, and Not Applicable.

Right away you see a problem. If this were an SAT test, say, where I actually cared whether or not I passed, I would summon a proctor and demand to know the difference between “Sometimes” and “Seldom,” or whether “Always” includes when I’m asleep, intoxicated, or filling out forms.

I will not burden you with all 26 questions. Instead, I’ll present several (these are the actual questions, folks, word for word), along with the answers I would have given had I not been hamstrung by the Six Categories. Each question is headed, “In the past 4 weeks.”

Q: How much have you felt little interest or pleasure?

A: I have very much felt little interest, and very little felt much interest. On the other hand, I have much interest in the little pleasure I have felt, and much pleasure in the little interest I have had.

Q: Has your physical and emotional health limited your social activities with family, friends, neighbors or groups?

A: No, but lack of money has.

Q: Have you needed help preparing your own meals?

A: Yes, ever since I got married, but that was more than 4 weeks ago. I can still make omelets, though.

Q: Are you having difficulties driving your car?

A: Do you know Boston drivers?

Q: Have you needed help managing your finances?

A: Not since 2008, and then it was my broker who needed the help.

Q: Have you needed help with household chores?

A: Never do ‘em.

Q: Do you have concerns about your memory?

A: What?

Q: DO YOU HAVE CONCERNS ABOUT YOUR MEMORY?

A: Not so much about what I can’t remember, mostly about what I can.

Q: Do any of your friends/family have concerns about your memory?

A: No, other than whether I’ll remember them in my will.

Q: Have you had sexual problems?

A: Too much. Too little. I forget. But that’s just the last 4 weeks. Six weeks ago was amazing.

Q: Have problems using a telephone?

A: Damn right. Cellular connectivity around here stinks.

Q: Do you exercise for about 20 minutes, 3 or more days a week?

A: I always exercise sometimes. I sometimes exercise always. Could you repeat the question?

Q: Does your home have throw rugs?

A: It has rugs, but nobody throws them.

Q: Does your home have poor lighting?

A: Ever since they outlawed incandescents. When I flip the switch, they’re fully lit by the time I finish breakfast, but by then it’s time to turn them off and go to work.

Q: During the past 4 weeks, how have things been going for you?

A: The Red Sox are doing lousy. Did you have to ask?

The form ends with thanks for taking the time to fill out the form and concludes with this cheery note: “Your responses will help you receive the best health and health care possible.”

When my physical was done, my doctor found the form in my paper pile. “I see you filled it out,” she said.

“By the way,” I asked her. ‘”What do you do with these forms?”

“Absolutely nothing,” she said.

“You don’t have to submit them for tabulation or something?”

“No,” she said.

If you’re not on Medicare yet, this is what you have to look forward to. Always.

Sometimes.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

sknews@frontlinemedcom.com

I got my Medicare card 2 years ago (guess how old I am?). At this year’s physical exam (my first exam under new rules that let Medicare pay for routine annual physicals), the clerk asked me to fill out the “Health-Risk Assessment” form my PCP would need for billing.

This form had two pages. Page 1 listed 26 questions, each to be answered by checking off one of the following six choices: Never, Sometimes, Seldom, Often, Always, and Not Applicable.

Right away you see a problem. If this were an SAT test, say, where I actually cared whether or not I passed, I would summon a proctor and demand to know the difference between “Sometimes” and “Seldom,” or whether “Always” includes when I’m asleep, intoxicated, or filling out forms.

I will not burden you with all 26 questions. Instead, I’ll present several (these are the actual questions, folks, word for word), along with the answers I would have given had I not been hamstrung by the Six Categories. Each question is headed, “In the past 4 weeks.”

Q: How much have you felt little interest or pleasure?

A: I have very much felt little interest, and very little felt much interest. On the other hand, I have much interest in the little pleasure I have felt, and much pleasure in the little interest I have had.

Q: Has your physical and emotional health limited your social activities with family, friends, neighbors or groups?

A: No, but lack of money has.

Q: Have you needed help preparing your own meals?

A: Yes, ever since I got married, but that was more than 4 weeks ago. I can still make omelets, though.

Q: Are you having difficulties driving your car?

A: Do you know Boston drivers?

Q: Have you needed help managing your finances?

A: Not since 2008, and then it was my broker who needed the help.

Q: Have you needed help with household chores?

A: Never do ‘em.

Q: Do you have concerns about your memory?

A: What?

Q: DO YOU HAVE CONCERNS ABOUT YOUR MEMORY?

A: Not so much about what I can’t remember, mostly about what I can.

Q: Do any of your friends/family have concerns about your memory?

A: No, other than whether I’ll remember them in my will.

Q: Have you had sexual problems?

A: Too much. Too little. I forget. But that’s just the last 4 weeks. Six weeks ago was amazing.

Q: Have problems using a telephone?

A: Damn right. Cellular connectivity around here stinks.

Q: Do you exercise for about 20 minutes, 3 or more days a week?

A: I always exercise sometimes. I sometimes exercise always. Could you repeat the question?

Q: Does your home have throw rugs?

A: It has rugs, but nobody throws them.

Q: Does your home have poor lighting?

A: Ever since they outlawed incandescents. When I flip the switch, they’re fully lit by the time I finish breakfast, but by then it’s time to turn them off and go to work.

Q: During the past 4 weeks, how have things been going for you?

A: The Red Sox are doing lousy. Did you have to ask?

The form ends with thanks for taking the time to fill out the form and concludes with this cheery note: “Your responses will help you receive the best health and health care possible.”

When my physical was done, my doctor found the form in my paper pile. “I see you filled it out,” she said.

“By the way,” I asked her. ‘”What do you do with these forms?”

“Absolutely nothing,” she said.

“You don’t have to submit them for tabulation or something?”

“No,” she said.

If you’re not on Medicare yet, this is what you have to look forward to. Always.

Sometimes.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

sknews@frontlinemedcom.com

I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.

"How’s the radiology business?" I asked him.

"Two more years," he said. "I should be able to hang on."

"That bad?"

"We were taken over by the academic department of a big teaching hospital," Peter said.

"What’s the problem? They want you to publish papers?" I asked.

"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."

"Measure what?"

"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."

You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.

"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."

"How about you?" I asked him. "Have they made you an offer you can’t refuse?"

"Not yet," he said.

Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.

"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."

Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.

The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.

Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.

"Yes," he said. "They just set that up recently."

"How did you find out?" I asked him.

"They sent out a memo," he said.

In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.

"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"

"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."

To say that hanging around colleagues who talk this way is dispiriting would be an understatement.

Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."

"I can see why," I said. "Whom do they take it out on?"

"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."

We agreed that seemed the best strategy.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.

"How’s the radiology business?" I asked him.

"Two more years," he said. "I should be able to hang on."

"That bad?"

"We were taken over by the academic department of a big teaching hospital," Peter said.

"What’s the problem? They want you to publish papers?" I asked.

"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."

"Measure what?"

"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."

You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.

"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."

"How about you?" I asked him. "Have they made you an offer you can’t refuse?"

"Not yet," he said.

Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.

"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."

Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.

The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.

Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.

"Yes," he said. "They just set that up recently."

"How did you find out?" I asked him.

"They sent out a memo," he said.

In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.

"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"

"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."

To say that hanging around colleagues who talk this way is dispiriting would be an understatement.

Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."

"I can see why," I said. "Whom do they take it out on?"

"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."

We agreed that seemed the best strategy.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.

"How’s the radiology business?" I asked him.

"Two more years," he said. "I should be able to hang on."

"That bad?"

"We were taken over by the academic department of a big teaching hospital," Peter said.

"What’s the problem? They want you to publish papers?" I asked.

"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."

"Measure what?"

"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."

You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.

"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."

"How about you?" I asked him. "Have they made you an offer you can’t refuse?"

"Not yet," he said.

Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.

"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."

Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.

The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.

Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.

"Yes," he said. "They just set that up recently."

"How did you find out?" I asked him.

"They sent out a memo," he said.

In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.

"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"

"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."

To say that hanging around colleagues who talk this way is dispiriting would be an understatement.

Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."

"I can see why," I said. "Whom do they take it out on?"

"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."

We agreed that seemed the best strategy.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

At 16, Eddie is tall and athletic. He’s been treating closed comedones on his forehead and chest off and on for a couple of years.

"I hope you can help him," his mother says. "There are days when he won’t go to school, he’s so embarrassed."

Really?

If you sat people down and asked them to list what people hate about their bodies, they wouldn’t come close to guessing what we dermatologists run into every day. Here are some cases I’ve seen lately. I’m sure you can easily come up with your own examples.

• A 50-year-old attorney with a wart on the dorsum of his right hand wanted me to take it off. "I sign a lot of documents," he said," and I’d prefer that clients remember me for my legal skills, not the wart on my hand."

• A 36-year-old waiter with a picker’s nodule over the proximal interphalangeal joint of his left fifth finger said I just had to get rid of it. "I’m a waiter," he said. "This is killing my tips."

• A 36-year-old woman gave up yoga a year ago, because she was sure the woman on the adjacent mat was disgusted by her plantar warts.

• A sprightly retiree, age 88(!), insisted on paying out of pocket to remove dermatosis papulosa nigra lesions from her face. Her explanation? "My children want me to stay at home, but I want to get out and be social!"

Self-consciousness doesn’t require lesions. For instance, I saw an 11-year-old last month with widespread atopic dermatitis, the kind that’s lifelong, miserably itchy, and hard to control. Yet she wasn’t even being treated. Why had she come now?

"What bothers you most about this?" I asked her.

"This brown patch on my neck," she said.

That’s right – not the itch, not the scratching, not the staying awake at night. What bothered her was the postinflammatory pigmentation on her neck that other kids would see and comment on.

She’s not alone. Another mother brought her 8-year-old daughter to see me. The girl’s eczema was being treated with nothing but moisturizer (which was "working, sort of").

"The reason we’re here," said Mom, "is that now she is starting to get self-conscious about the dark staining on her hand."

As doctors, we’re trained to think functionally so we can measure the ways disease impairs functionality: length of life, duration of fever, days out of work, oxygen saturation, percentage of involved body surface.

But you can’t measure shame. Nor can you predict what will produce it. Even after all these years, people surprise me all the time.

The secondary codes some insurers demand to cover wart treatment include pain, rapid growth, or bleeding. They do not include, "Clients are staring at my hand at real estate closings." Or, "This bump is reducing my tips." We could, of course, tell people not to mind being stared at, but they will not agree. They know how people look at them, and what parts of them they look at.

If any of us had a big welt over one eye, we might think twice before going to work, knowing that every patient and staff member are going to ask, "What bar were you in, and what does the other guy look like?" The teenager with the stain on her neck and the boy with the papules on his forehead and chest feel that way every morning.

Basically, nobody wants to stand out. If we do, we’d like it to be for some admirable quality. The truth is, we shouldn’t really take credit for being called handsome, smart, or healthy, but we do anyway. By the same token, it’s not our fault if we’re ill or different, but being singled out for either makes things worse – not functionally, just humanly.

Many years ago, a 15-year-old girl asked me to take off a mole from the top of her foot.

"The mole’s fine," I said. "Why do you want it off?"

"It’s embarrassing," she said.

"How?" I asked her. "Don’t you go to pools in the summer?"

"I stand with the one foot covering the spot on the other foot. Nobody has ever seen it."

Not everything people are embarrassed about can be removed with a cream or a hyfrecator. But shame is powerful, and we need to recognize it for what it is so we can address it if we can.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

At 16, Eddie is tall and athletic. He’s been treating closed comedones on his forehead and chest off and on for a couple of years.

"I hope you can help him," his mother says. "There are days when he won’t go to school, he’s so embarrassed."

Really?

If you sat people down and asked them to list what people hate about their bodies, they wouldn’t come close to guessing what we dermatologists run into every day. Here are some cases I’ve seen lately. I’m sure you can easily come up with your own examples.

• A 50-year-old attorney with a wart on the dorsum of his right hand wanted me to take it off. "I sign a lot of documents," he said," and I’d prefer that clients remember me for my legal skills, not the wart on my hand."

• A 36-year-old waiter with a picker’s nodule over the proximal interphalangeal joint of his left fifth finger said I just had to get rid of it. "I’m a waiter," he said. "This is killing my tips."

• A 36-year-old woman gave up yoga a year ago, because she was sure the woman on the adjacent mat was disgusted by her plantar warts.

• A sprightly retiree, age 88(!), insisted on paying out of pocket to remove dermatosis papulosa nigra lesions from her face. Her explanation? "My children want me to stay at home, but I want to get out and be social!"

Self-consciousness doesn’t require lesions. For instance, I saw an 11-year-old last month with widespread atopic dermatitis, the kind that’s lifelong, miserably itchy, and hard to control. Yet she wasn’t even being treated. Why had she come now?

"What bothers you most about this?" I asked her.

"This brown patch on my neck," she said.

That’s right – not the itch, not the scratching, not the staying awake at night. What bothered her was the postinflammatory pigmentation on her neck that other kids would see and comment on.

She’s not alone. Another mother brought her 8-year-old daughter to see me. The girl’s eczema was being treated with nothing but moisturizer (which was "working, sort of").

"The reason we’re here," said Mom, "is that now she is starting to get self-conscious about the dark staining on her hand."

As doctors, we’re trained to think functionally so we can measure the ways disease impairs functionality: length of life, duration of fever, days out of work, oxygen saturation, percentage of involved body surface.

But you can’t measure shame. Nor can you predict what will produce it. Even after all these years, people surprise me all the time.

The secondary codes some insurers demand to cover wart treatment include pain, rapid growth, or bleeding. They do not include, "Clients are staring at my hand at real estate closings." Or, "This bump is reducing my tips." We could, of course, tell people not to mind being stared at, but they will not agree. They know how people look at them, and what parts of them they look at.

If any of us had a big welt over one eye, we might think twice before going to work, knowing that every patient and staff member are going to ask, "What bar were you in, and what does the other guy look like?" The teenager with the stain on her neck and the boy with the papules on his forehead and chest feel that way every morning.

Basically, nobody wants to stand out. If we do, we’d like it to be for some admirable quality. The truth is, we shouldn’t really take credit for being called handsome, smart, or healthy, but we do anyway. By the same token, it’s not our fault if we’re ill or different, but being singled out for either makes things worse – not functionally, just humanly.

Many years ago, a 15-year-old girl asked me to take off a mole from the top of her foot.

"The mole’s fine," I said. "Why do you want it off?"

"It’s embarrassing," she said.

"How?" I asked her. "Don’t you go to pools in the summer?"

"I stand with the one foot covering the spot on the other foot. Nobody has ever seen it."

Not everything people are embarrassed about can be removed with a cream or a hyfrecator. But shame is powerful, and we need to recognize it for what it is so we can address it if we can.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

At 16, Eddie is tall and athletic. He’s been treating closed comedones on his forehead and chest off and on for a couple of years.

"I hope you can help him," his mother says. "There are days when he won’t go to school, he’s so embarrassed."

Really?

If you sat people down and asked them to list what people hate about their bodies, they wouldn’t come close to guessing what we dermatologists run into every day. Here are some cases I’ve seen lately. I’m sure you can easily come up with your own examples.

• A 50-year-old attorney with a wart on the dorsum of his right hand wanted me to take it off. "I sign a lot of documents," he said," and I’d prefer that clients remember me for my legal skills, not the wart on my hand."

• A 36-year-old waiter with a picker’s nodule over the proximal interphalangeal joint of his left fifth finger said I just had to get rid of it. "I’m a waiter," he said. "This is killing my tips."

• A 36-year-old woman gave up yoga a year ago, because she was sure the woman on the adjacent mat was disgusted by her plantar warts.

• A sprightly retiree, age 88(!), insisted on paying out of pocket to remove dermatosis papulosa nigra lesions from her face. Her explanation? "My children want me to stay at home, but I want to get out and be social!"

Self-consciousness doesn’t require lesions. For instance, I saw an 11-year-old last month with widespread atopic dermatitis, the kind that’s lifelong, miserably itchy, and hard to control. Yet she wasn’t even being treated. Why had she come now?

"What bothers you most about this?" I asked her.

"This brown patch on my neck," she said.

That’s right – not the itch, not the scratching, not the staying awake at night. What bothered her was the postinflammatory pigmentation on her neck that other kids would see and comment on.

She’s not alone. Another mother brought her 8-year-old daughter to see me. The girl’s eczema was being treated with nothing but moisturizer (which was "working, sort of").

"The reason we’re here," said Mom, "is that now she is starting to get self-conscious about the dark staining on her hand."

As doctors, we’re trained to think functionally so we can measure the ways disease impairs functionality: length of life, duration of fever, days out of work, oxygen saturation, percentage of involved body surface.

But you can’t measure shame. Nor can you predict what will produce it. Even after all these years, people surprise me all the time.

The secondary codes some insurers demand to cover wart treatment include pain, rapid growth, or bleeding. They do not include, "Clients are staring at my hand at real estate closings." Or, "This bump is reducing my tips." We could, of course, tell people not to mind being stared at, but they will not agree. They know how people look at them, and what parts of them they look at.

If any of us had a big welt over one eye, we might think twice before going to work, knowing that every patient and staff member are going to ask, "What bar were you in, and what does the other guy look like?" The teenager with the stain on her neck and the boy with the papules on his forehead and chest feel that way every morning.

Basically, nobody wants to stand out. If we do, we’d like it to be for some admirable quality. The truth is, we shouldn’t really take credit for being called handsome, smart, or healthy, but we do anyway. By the same token, it’s not our fault if we’re ill or different, but being singled out for either makes things worse – not functionally, just humanly.

Many years ago, a 15-year-old girl asked me to take off a mole from the top of her foot.

"The mole’s fine," I said. "Why do you want it off?"

"It’s embarrassing," she said.

"How?" I asked her. "Don’t you go to pools in the summer?"

"I stand with the one foot covering the spot on the other foot. Nobody has ever seen it."

Not everything people are embarrassed about can be removed with a cream or a hyfrecator. But shame is powerful, and we need to recognize it for what it is so we can address it if we can.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

"Hard cases," say the lawyers, "make bad law." That means something like, "Legislation works better when it’s drafted in response to average circumstances, not extreme ones."

This adage applies to our profession, too. You can learn more about how to practice and teach medicine from average cases than from rare and strange ones. Hard cases can make any of us look foolish.

Peter e-mailed me the other day. I’d seen him 6 months ago for an eczematous rash on his back. Something funny about it, though: The distribution didn’t work, and it wasn’t scaly. No response to triamcinolone. Biopsy: Nonspecific inflammation. CBC: Elevated white cells at 15,600, mostly lymphs. Hmmm.

I referred him to an academic center. They presented him at Grand Rounds, and set him up for patch testing. He avoided what they asked him to, with little success.

"The oncologist says I have lymphoma," Peter’s e-mail to the patch test clinic read, copying me. He apologetically canceled his allergy clinic follow-up. "I hope for a good prognosis, although diagnosis has been delayed for several months. I hope my example will be of value for future patients."

Peter puts his regrets gently. How valuable will his lesson be? His case teaches that strange presentations of uncommon conditions can make even good and conscientious doctors look lame.

We all congratulate ourselves on "good pick-ups," the diagnostic coups that hit the nail on the head. Fair enough, but we understandably look away when we got it right by dumb luck or got it wrong.

That subcutaneous fullness we thought was fine, but which the patient insisted be removed (and turned out to be dermatofibrosarcoma protuberans). That dark spot that looked like all the others, only the patient was nervous because he was sure it had changed (melanoma). The funny rash that ended up being measles in an unimmunized child, and when was the last time you saw measles?

Often, we never even find out about the hard cases we missed, because the people who had them got fed up with us and went elsewhere. Sometimes, they send an angry letter or – more common these days – write a bad review. "I went to another doctor who finally figured out my problem and prescribed the right treatment." Once in a while, a lawsuit.

Viewed through the "retrospectoscope," knowing how the story turned out, our initial fumblings look pretty clumsy, if not downright actionable. "Oh, come on," a critic might say, "Surely that lump was too irregular for you to pass it off as a fibroma." Or: "Why the surprise? Didn’t he tell you the mole changed?" "The kid was sick and had a funny rash, didn’t she?" says a third. "Don’t you read the papers about all the parents who won’t vaccinate their children for fear of autism?"

I’m not suggesting that these are bad questions or that we shouldn’t ask them, so we can learn what we can. What I am saying is that, even if we do, no matter how careful and thoughtful we are, we are never going to catch everything we are unprepared for – the rare, the atypical, the unexpected.

This spring, the media reported details of an outbreak that occurred 5 years ago at New Orleans Children’s Hospital of what turned out to be mucormycosis; it proved fatal for several children. Looking back, mistakes were made. Diagnostic biopsies were only done when parents demanded them. Soiled laundry was mishandled. All this at a well-respected tertiary care center staffed by clinicians no doubt as fine as specialists anywhere.

The resulting investigation will no doubt find clinical and administrative gaps and address them. Consciousness will be raised, systems streamlined, oversight tightened. This loophole will be closed. Then others will open, no doubt the way they usually do, when people are looking at something else.

I knew there was something fishy about Peter’s case, but I didn’t know what it was. The experienced and thoughtful academic physicians I sent him to didn’t figure it out, either. It is nice of Peter to be philosophical about this. I would not begrudge him a less considerate reaction.

As for us, we ought to be vigilant, thorough, and humble. Should we get full of ourselves, there’s a hard case out there just waiting to deflate us.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

"Hard cases," say the lawyers, "make bad law." That means something like, "Legislation works better when it’s drafted in response to average circumstances, not extreme ones."

This adage applies to our profession, too. You can learn more about how to practice and teach medicine from average cases than from rare and strange ones. Hard cases can make any of us look foolish.

Peter e-mailed me the other day. I’d seen him 6 months ago for an eczematous rash on his back. Something funny about it, though: The distribution didn’t work, and it wasn’t scaly. No response to triamcinolone. Biopsy: Nonspecific inflammation. CBC: Elevated white cells at 15,600, mostly lymphs. Hmmm.

I referred him to an academic center. They presented him at Grand Rounds, and set him up for patch testing. He avoided what they asked him to, with little success.

"The oncologist says I have lymphoma," Peter’s e-mail to the patch test clinic read, copying me. He apologetically canceled his allergy clinic follow-up. "I hope for a good prognosis, although diagnosis has been delayed for several months. I hope my example will be of value for future patients."

Peter puts his regrets gently. How valuable will his lesson be? His case teaches that strange presentations of uncommon conditions can make even good and conscientious doctors look lame.

We all congratulate ourselves on "good pick-ups," the diagnostic coups that hit the nail on the head. Fair enough, but we understandably look away when we got it right by dumb luck or got it wrong.

That subcutaneous fullness we thought was fine, but which the patient insisted be removed (and turned out to be dermatofibrosarcoma protuberans). That dark spot that looked like all the others, only the patient was nervous because he was sure it had changed (melanoma). The funny rash that ended up being measles in an unimmunized child, and when was the last time you saw measles?

Often, we never even find out about the hard cases we missed, because the people who had them got fed up with us and went elsewhere. Sometimes, they send an angry letter or – more common these days – write a bad review. "I went to another doctor who finally figured out my problem and prescribed the right treatment." Once in a while, a lawsuit.

Viewed through the "retrospectoscope," knowing how the story turned out, our initial fumblings look pretty clumsy, if not downright actionable. "Oh, come on," a critic might say, "Surely that lump was too irregular for you to pass it off as a fibroma." Or: "Why the surprise? Didn’t he tell you the mole changed?" "The kid was sick and had a funny rash, didn’t she?" says a third. "Don’t you read the papers about all the parents who won’t vaccinate their children for fear of autism?"

I’m not suggesting that these are bad questions or that we shouldn’t ask them, so we can learn what we can. What I am saying is that, even if we do, no matter how careful and thoughtful we are, we are never going to catch everything we are unprepared for – the rare, the atypical, the unexpected.

This spring, the media reported details of an outbreak that occurred 5 years ago at New Orleans Children’s Hospital of what turned out to be mucormycosis; it proved fatal for several children. Looking back, mistakes were made. Diagnostic biopsies were only done when parents demanded them. Soiled laundry was mishandled. All this at a well-respected tertiary care center staffed by clinicians no doubt as fine as specialists anywhere.

The resulting investigation will no doubt find clinical and administrative gaps and address them. Consciousness will be raised, systems streamlined, oversight tightened. This loophole will be closed. Then others will open, no doubt the way they usually do, when people are looking at something else.

I knew there was something fishy about Peter’s case, but I didn’t know what it was. The experienced and thoughtful academic physicians I sent him to didn’t figure it out, either. It is nice of Peter to be philosophical about this. I would not begrudge him a less considerate reaction.

As for us, we ought to be vigilant, thorough, and humble. Should we get full of ourselves, there’s a hard case out there just waiting to deflate us.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

"Hard cases," say the lawyers, "make bad law." That means something like, "Legislation works better when it’s drafted in response to average circumstances, not extreme ones."

This adage applies to our profession, too. You can learn more about how to practice and teach medicine from average cases than from rare and strange ones. Hard cases can make any of us look foolish.

Peter e-mailed me the other day. I’d seen him 6 months ago for an eczematous rash on his back. Something funny about it, though: The distribution didn’t work, and it wasn’t scaly. No response to triamcinolone. Biopsy: Nonspecific inflammation. CBC: Elevated white cells at 15,600, mostly lymphs. Hmmm.

I referred him to an academic center. They presented him at Grand Rounds, and set him up for patch testing. He avoided what they asked him to, with little success.

"The oncologist says I have lymphoma," Peter’s e-mail to the patch test clinic read, copying me. He apologetically canceled his allergy clinic follow-up. "I hope for a good prognosis, although diagnosis has been delayed for several months. I hope my example will be of value for future patients."

Peter puts his regrets gently. How valuable will his lesson be? His case teaches that strange presentations of uncommon conditions can make even good and conscientious doctors look lame.

We all congratulate ourselves on "good pick-ups," the diagnostic coups that hit the nail on the head. Fair enough, but we understandably look away when we got it right by dumb luck or got it wrong.

That subcutaneous fullness we thought was fine, but which the patient insisted be removed (and turned out to be dermatofibrosarcoma protuberans). That dark spot that looked like all the others, only the patient was nervous because he was sure it had changed (melanoma). The funny rash that ended up being measles in an unimmunized child, and when was the last time you saw measles?

Often, we never even find out about the hard cases we missed, because the people who had them got fed up with us and went elsewhere. Sometimes, they send an angry letter or – more common these days – write a bad review. "I went to another doctor who finally figured out my problem and prescribed the right treatment." Once in a while, a lawsuit.

Viewed through the "retrospectoscope," knowing how the story turned out, our initial fumblings look pretty clumsy, if not downright actionable. "Oh, come on," a critic might say, "Surely that lump was too irregular for you to pass it off as a fibroma." Or: "Why the surprise? Didn’t he tell you the mole changed?" "The kid was sick and had a funny rash, didn’t she?" says a third. "Don’t you read the papers about all the parents who won’t vaccinate their children for fear of autism?"

I’m not suggesting that these are bad questions or that we shouldn’t ask them, so we can learn what we can. What I am saying is that, even if we do, no matter how careful and thoughtful we are, we are never going to catch everything we are unprepared for – the rare, the atypical, the unexpected.

This spring, the media reported details of an outbreak that occurred 5 years ago at New Orleans Children’s Hospital of what turned out to be mucormycosis; it proved fatal for several children. Looking back, mistakes were made. Diagnostic biopsies were only done when parents demanded them. Soiled laundry was mishandled. All this at a well-respected tertiary care center staffed by clinicians no doubt as fine as specialists anywhere.

The resulting investigation will no doubt find clinical and administrative gaps and address them. Consciousness will be raised, systems streamlined, oversight tightened. This loophole will be closed. Then others will open, no doubt the way they usually do, when people are looking at something else.

I knew there was something fishy about Peter’s case, but I didn’t know what it was. The experienced and thoughtful academic physicians I sent him to didn’t figure it out, either. It is nice of Peter to be philosophical about this. I would not begrudge him a less considerate reaction.

As for us, we ought to be vigilant, thorough, and humble. Should we get full of ourselves, there’s a hard case out there just waiting to deflate us.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Who do you call when your windshield’s busted?

Call Giant Glass!

There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.

Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"

If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.

Or why Beth Israel Deaconess is the Red Sox Official Hospital.

You can see where I’m going with this, can’t you?

In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)

I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.

*******************

Marriott Hotels

Dear Mr. or Ms. Marriott:

I salute you as Official Hotel of the Red Sox!

But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?

Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.

Our rates are reasonable. Give us a call!

*******************

Dunkin’ Donuts

Dear Donuts:

It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!

I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?

That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)

*******************

John Hancock Insurance

Dear Mr. Hancock,

Congratulations on being the Official Insurance of the Boston Red Sox.

I just love your building, a real Boston landmark.

Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)

While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.

Let’s do lunch. Do you like Dunkin’ Donuts?

*******************

You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.

Here’s a sample letter:

Toledo Mud Hens

Toledo, Ohio

Dear Mud Hens,

I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.

Let’s all get together and triangulate.

Go Mud Hens!

*******************

OK, colleagues, I’ve given you direction. Now get out there and make it happen!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Who do you call when your windshield’s busted?

Call Giant Glass!

There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.

Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"

If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.

Or why Beth Israel Deaconess is the Red Sox Official Hospital.

You can see where I’m going with this, can’t you?

In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)

I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.

*******************

Marriott Hotels

Dear Mr. or Ms. Marriott:

I salute you as Official Hotel of the Red Sox!

But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?

Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.

Our rates are reasonable. Give us a call!

*******************

Dunkin’ Donuts

Dear Donuts:

It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!

I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?

That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)

*******************

John Hancock Insurance

Dear Mr. Hancock,

Congratulations on being the Official Insurance of the Boston Red Sox.

I just love your building, a real Boston landmark.

Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)

While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.

Let’s do lunch. Do you like Dunkin’ Donuts?

*******************

You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.

Here’s a sample letter:

Toledo Mud Hens

Toledo, Ohio

Dear Mud Hens,

I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.

Let’s all get together and triangulate.

Go Mud Hens!

*******************

OK, colleagues, I’ve given you direction. Now get out there and make it happen!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Who do you call when your windshield’s busted?

Call Giant Glass!

There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.

Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"

If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.

Or why Beth Israel Deaconess is the Red Sox Official Hospital.

You can see where I’m going with this, can’t you?

In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)

I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.

*******************

Marriott Hotels

Dear Mr. or Ms. Marriott:

I salute you as Official Hotel of the Red Sox!

But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?

Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.

Our rates are reasonable. Give us a call!

*******************

Dunkin’ Donuts

Dear Donuts:

It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!

I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?

That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)

*******************

John Hancock Insurance

Dear Mr. Hancock,

Congratulations on being the Official Insurance of the Boston Red Sox.

I just love your building, a real Boston landmark.

Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)

While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.

Let’s do lunch. Do you like Dunkin’ Donuts?

*******************

You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.

Here’s a sample letter:

Toledo Mud Hens

Toledo, Ohio

Dear Mud Hens,

I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.

Let’s all get together and triangulate.

Go Mud Hens!

*******************

OK, colleagues, I’ve given you direction. Now get out there and make it happen!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

It was the worst of days. It was the best of days.

When I opened the mail one day last week, I found a letter from someone I’ll call Thelma. It read, in part:

"Last Monday you were kind enough to look at my rash, which you thought was just eczema. You gave me cream and asked me to e-mail you Thursday about my condition. When I did and said I was still itchy, you said I should stick with the same and that I could come back Monday, but I couldn’t wait because I itched so bad I couldn’t take it anymore. I saw another doctor Friday who said the patch was host to something called pityriasis rosea. He said the rash was so textbook it should have been picked up immediately. I had to be put on an oral steroid right away.

"I am so upset that I’m sending you back your bill [for a $15 co-pay] because I had to go to another doctor who could really help me."

I thought of a few choice words for my esteemed Friday colleague, but kept them to myself. A single scaly patch is a textbook case of pityriasis rosea? Oral steroids for pityriasis? Really?

As far as this patient is concerned, I must be a bum. Thirty-five years on the job, and I haven’t mastered the textbook yet.

Sunk in gloom, I opened an e-mail sent to my website by a patient I’ll call Louise:

"I suffer from psoriasis and have been to countless dermatologists since I was 8 years old. I recently had a terrible outbreak and was really hesitant to even go to a dermatologist because I’ve never been satisfied with any of them. Your associate is wonderful! I can’t say enough about her. She is warm, thorough, and really takes the time to sit with you and listen. You can tell she truly cares about her patients and loves her job."

I looked at the patient’s chart. What was the wonderful and satisfying treatment that my associate had prescribed to deal with this patient’s lifelong, recalcitrant psoriasis?

Betamethasone dipropionate cream 0.05%. Wow.

I e-mailed my associate at once and we shared a gratified chuckle. Guess no one ever thought of treating Louise’s psoriasis with a topical steroid before. We must be geniuses, right out there on the cutting edge.

So which are we, dear colleagues – geniuses or bums?

We’re neither, of course, which doesn’t stop our patients from forming firm opinions one way or the other. Which they can share by angry letter, fulsome e-mail, or, of course, any on-line reviews they can slip past the mysterious algorithms of the Yelps and Angie’s Lists of the world.

When I get messages like Thelma’s and Louise’s, I show them to my students and make three suggestions:

• Don’t try to look smart at someone else’s expense. Next time around a patient will be in somebody else’s office calling you a fool.

• Don’t respond to snippy patients’ complaints by contacting the complainer and trying to justify yourself. Learn something if you can, and move on.

• Be grateful for praise. Just don’t take it too seriously.

In the meantime, the insurers and assorted bureaucrats who run our lives these days are busy defining good care and claiming to measure it so they can reward quality and punish inefficiency. I’m sure they think they’re doing a fine job, although I remain deeply skeptical that what they choose to measure has much relevance to what actually goes on in offices like ours.

I could, of course, try to tell them why I think so. (I have tried, in fact.) Getting through to people with a completely different way of looking at things than yours is not very rewarding, even when large sums of money are not involved. I would have as good a chance of winning them over as I would of convincing Thelma that a scaly patch is not textbook pityriasis that needs prednisone and Louise that betamethasone cream is not the breakthrough that will change her life.

So: Not the best of times. Not the worst of times. Just another day at the office.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

It was the worst of days. It was the best of days.

When I opened the mail one day last week, I found a letter from someone I’ll call Thelma. It read, in part:

"Last Monday you were kind enough to look at my rash, which you thought was just eczema. You gave me cream and asked me to e-mail you Thursday about my condition. When I did and said I was still itchy, you said I should stick with the same and that I could come back Monday, but I couldn’t wait because I itched so bad I couldn’t take it anymore. I saw another doctor Friday who said the patch was host to something called pityriasis rosea. He said the rash was so textbook it should have been picked up immediately. I had to be put on an oral steroid right away.

"I am so upset that I’m sending you back your bill [for a $15 co-pay] because I had to go to another doctor who could really help me."

I thought of a few choice words for my esteemed Friday colleague, but kept them to myself. A single scaly patch is a textbook case of pityriasis rosea? Oral steroids for pityriasis? Really?

As far as this patient is concerned, I must be a bum. Thirty-five years on the job, and I haven’t mastered the textbook yet.

Sunk in gloom, I opened an e-mail sent to my website by a patient I’ll call Louise:

"I suffer from psoriasis and have been to countless dermatologists since I was 8 years old. I recently had a terrible outbreak and was really hesitant to even go to a dermatologist because I’ve never been satisfied with any of them. Your associate is wonderful! I can’t say enough about her. She is warm, thorough, and really takes the time to sit with you and listen. You can tell she truly cares about her patients and loves her job."

I looked at the patient’s chart. What was the wonderful and satisfying treatment that my associate had prescribed to deal with this patient’s lifelong, recalcitrant psoriasis?

Betamethasone dipropionate cream 0.05%. Wow.

I e-mailed my associate at once and we shared a gratified chuckle. Guess no one ever thought of treating Louise’s psoriasis with a topical steroid before. We must be geniuses, right out there on the cutting edge.

So which are we, dear colleagues – geniuses or bums?

We’re neither, of course, which doesn’t stop our patients from forming firm opinions one way or the other. Which they can share by angry letter, fulsome e-mail, or, of course, any on-line reviews they can slip past the mysterious algorithms of the Yelps and Angie’s Lists of the world.

When I get messages like Thelma’s and Louise’s, I show them to my students and make three suggestions:

• Don’t try to look smart at someone else’s expense. Next time around a patient will be in somebody else’s office calling you a fool.

• Don’t respond to snippy patients’ complaints by contacting the complainer and trying to justify yourself. Learn something if you can, and move on.

• Be grateful for praise. Just don’t take it too seriously.

In the meantime, the insurers and assorted bureaucrats who run our lives these days are busy defining good care and claiming to measure it so they can reward quality and punish inefficiency. I’m sure they think they’re doing a fine job, although I remain deeply skeptical that what they choose to measure has much relevance to what actually goes on in offices like ours.

I could, of course, try to tell them why I think so. (I have tried, in fact.) Getting through to people with a completely different way of looking at things than yours is not very rewarding, even when large sums of money are not involved. I would have as good a chance of winning them over as I would of convincing Thelma that a scaly patch is not textbook pityriasis that needs prednisone and Louise that betamethasone cream is not the breakthrough that will change her life.

So: Not the best of times. Not the worst of times. Just another day at the office.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

It was the worst of days. It was the best of days.

When I opened the mail one day last week, I found a letter from someone I’ll call Thelma. It read, in part:

"Last Monday you were kind enough to look at my rash, which you thought was just eczema. You gave me cream and asked me to e-mail you Thursday about my condition. When I did and said I was still itchy, you said I should stick with the same and that I could come back Monday, but I couldn’t wait because I itched so bad I couldn’t take it anymore. I saw another doctor Friday who said the patch was host to something called pityriasis rosea. He said the rash was so textbook it should have been picked up immediately. I had to be put on an oral steroid right away.

"I am so upset that I’m sending you back your bill [for a $15 co-pay] because I had to go to another doctor who could really help me."

I thought of a few choice words for my esteemed Friday colleague, but kept them to myself. A single scaly patch is a textbook case of pityriasis rosea? Oral steroids for pityriasis? Really?

As far as this patient is concerned, I must be a bum. Thirty-five years on the job, and I haven’t mastered the textbook yet.

Sunk in gloom, I opened an e-mail sent to my website by a patient I’ll call Louise:

"I suffer from psoriasis and have been to countless dermatologists since I was 8 years old. I recently had a terrible outbreak and was really hesitant to even go to a dermatologist because I’ve never been satisfied with any of them. Your associate is wonderful! I can’t say enough about her. She is warm, thorough, and really takes the time to sit with you and listen. You can tell she truly cares about her patients and loves her job."

I looked at the patient’s chart. What was the wonderful and satisfying treatment that my associate had prescribed to deal with this patient’s lifelong, recalcitrant psoriasis?

Betamethasone dipropionate cream 0.05%. Wow.

I e-mailed my associate at once and we shared a gratified chuckle. Guess no one ever thought of treating Louise’s psoriasis with a topical steroid before. We must be geniuses, right out there on the cutting edge.

So which are we, dear colleagues – geniuses or bums?

We’re neither, of course, which doesn’t stop our patients from forming firm opinions one way or the other. Which they can share by angry letter, fulsome e-mail, or, of course, any on-line reviews they can slip past the mysterious algorithms of the Yelps and Angie’s Lists of the world.

When I get messages like Thelma’s and Louise’s, I show them to my students and make three suggestions:

• Don’t try to look smart at someone else’s expense. Next time around a patient will be in somebody else’s office calling you a fool.

• Don’t respond to snippy patients’ complaints by contacting the complainer and trying to justify yourself. Learn something if you can, and move on.

• Be grateful for praise. Just don’t take it too seriously.

In the meantime, the insurers and assorted bureaucrats who run our lives these days are busy defining good care and claiming to measure it so they can reward quality and punish inefficiency. I’m sure they think they’re doing a fine job, although I remain deeply skeptical that what they choose to measure has much relevance to what actually goes on in offices like ours.

I could, of course, try to tell them why I think so. (I have tried, in fact.) Getting through to people with a completely different way of looking at things than yours is not very rewarding, even when large sums of money are not involved. I would have as good a chance of winning them over as I would of convincing Thelma that a scaly patch is not textbook pityriasis that needs prednisone and Louise that betamethasone cream is not the breakthrough that will change her life.

So: Not the best of times. Not the worst of times. Just another day at the office.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Students who spend a month with me always want a session on topical steroids, that great undiscovered world they have to know but dread to explore. They’ve all seen those tables of steroid potency based on the rabbit-ear bioassay. These run to long columns (or several pages) of small print ordering the steroid universe from the aristocracy of Class 1 ("Supernovacort" 0.015%) down through the midrange ("Mediocricort" 0.026% ointment is Class 2, while Mediocricort 0.026% cream is only Class 3), down to the humble "Trivialicort" 32%, which on a good day is just a measly Class 6. All those multisyllabic names and numbers and classes bewilder and intimidate the poor kids. Even their earnest medical-student memorization skills leave them in despair of mastering all this stuff.

I ask them to ponder a mini-scenario: Your patient was given a topical steroid cream. He says it didn’t work. List all possible explanations.

The next day we discuss their answers. Most students manage to come up with several types of reasons. Maybe the steroid didn’t work because the diagnosis was wrong. (It was a fungus.) Perhaps the condition is inherently unresponsive (like knee psoriasis). Sometimes, the patient didn’t use the cream.

Then we break down that third category. Why would a patient not use the cream? Reasons include:

• The tube was too small (15 g for a full-body rash).

• The steroid did work, but the patient thought it didn’t because the eczema came back. (Eczema comes back.)

• The patient was afraid of steroids. ("I heard they thin your skin.")

I end our session by noting that this third group (the patient didn’t use the cream) is a) intellectually uninteresting; and b) the reason behind most cases were "the steroid didn’t work." By contrast, using the wrong steroid – as defined by the fine-grained distinctions on steroid potency tables – is rarely the difference between success and failure.

I give students a list of four generics, from weak to strong, and advise them not to clutter up their brains with any others. (Since most of them are headed for primary care, those four will be plenty, freeing brain space for board memorization.)

Ever since medical school, which is a rather long time ago by now, I’ve wondered why some things are taught and others left out. More particularly, why are some kinds of facts thought to be important (the ones you can quantify or put numbers next to, for instance) and others are too squishy to mention (such as knowing what the patient thinks about the treatment)?

After all, knowing what a patient thinks about what a treatment does – how it might harm them, and what a treatment "working" really means – has a lot to do with whether the treatment is used properly, or used at all. Why isn’t that important? Because you can’t put it into a table laced with decimal points and percentages?

The tendency to reduce everything to what you can measure has been around for a long time but seems to be getting worse. I read the other day about something called the Human Connectome Project, an effort to produce data to help answer the central question, "How do differences between you and me and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, and our experiences?"

I am not the first to wonder whether functional MRIs, with those gaily colored snapshots of the brain in action, really tell us more about how the brain works than does talking with the people who own those brains. The assumption seems to be that pictures of brain circuits are "real," whereas mere talk is mush, not the stuff of science, whose fruits we physicians are supposed to apply. I am wired, therefore I am.

Suppose a patient thinks that topical steroids thin the skin? Suppose she expects your eczema cream to make the rash go away once and for all, and when it comes back, she takes that as proof that it "didn’t work" and stops using it because it’s clearly worthless? Would those opinions show up on a color photo of her amygdala?

Can my patients be the only ones whose opinions about health and disease matter more, and more often, than do the tabulated measures of clinical efficacy?

You know, the real stuff you have to memorize and document, to get in and to get by.

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. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Students who spend a month with me always want a session on topical steroids, that great undiscovered world they have to know but dread to explore. They’ve all seen those tables of steroid potency based on the rabbit-ear bioassay. These run to long columns (or several pages) of small print ordering the steroid universe from the aristocracy of Class 1 ("Supernovacort" 0.015%) down through the midrange ("Mediocricort" 0.026% ointment is Class 2, while Mediocricort 0.026% cream is only Class 3), down to the humble "Trivialicort" 32%, which on a good day is just a measly Class 6. All those multisyllabic names and numbers and classes bewilder and intimidate the poor kids. Even their earnest medical-student memorization skills leave them in despair of mastering all this stuff.

I ask them to ponder a mini-scenario: Your patient was given a topical steroid cream. He says it didn’t work. List all possible explanations.

The next day we discuss their answers. Most students manage to come up with several types of reasons. Maybe the steroid didn’t work because the diagnosis was wrong. (It was a fungus.) Perhaps the condition is inherently unresponsive (like knee psoriasis). Sometimes, the patient didn’t use the cream.

Then we break down that third category. Why would a patient not use the cream? Reasons include:

• The tube was too small (15 g for a full-body rash).

• The steroid did work, but the patient thought it didn’t because the eczema came back. (Eczema comes back.)

• The patient was afraid of steroids. ("I heard they thin your skin.")

I end our session by noting that this third group (the patient didn’t use the cream) is a) intellectually uninteresting; and b) the reason behind most cases were "the steroid didn’t work." By contrast, using the wrong steroid – as defined by the fine-grained distinctions on steroid potency tables – is rarely the difference between success and failure.

I give students a list of four generics, from weak to strong, and advise them not to clutter up their brains with any others. (Since most of them are headed for primary care, those four will be plenty, freeing brain space for board memorization.)

Ever since medical school, which is a rather long time ago by now, I’ve wondered why some things are taught and others left out. More particularly, why are some kinds of facts thought to be important (the ones you can quantify or put numbers next to, for instance) and others are too squishy to mention (such as knowing what the patient thinks about the treatment)?

After all, knowing what a patient thinks about what a treatment does – how it might harm them, and what a treatment "working" really means – has a lot to do with whether the treatment is used properly, or used at all. Why isn’t that important? Because you can’t put it into a table laced with decimal points and percentages?

The tendency to reduce everything to what you can measure has been around for a long time but seems to be getting worse. I read the other day about something called the Human Connectome Project, an effort to produce data to help answer the central question, "How do differences between you and me and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, and our experiences?"

I am not the first to wonder whether functional MRIs, with those gaily colored snapshots of the brain in action, really tell us more about how the brain works than does talking with the people who own those brains. The assumption seems to be that pictures of brain circuits are "real," whereas mere talk is mush, not the stuff of science, whose fruits we physicians are supposed to apply. I am wired, therefore I am.

Suppose a patient thinks that topical steroids thin the skin? Suppose she expects your eczema cream to make the rash go away once and for all, and when it comes back, she takes that as proof that it "didn’t work" and stops using it because it’s clearly worthless? Would those opinions show up on a color photo of her amygdala?

Can my patients be the only ones whose opinions about health and disease matter more, and more often, than do the tabulated measures of clinical efficacy?

You know, the real stuff you have to memorize and document, to get in and to get by.

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. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Students who spend a month with me always want a session on topical steroids, that great undiscovered world they have to know but dread to explore. They’ve all seen those tables of steroid potency based on the rabbit-ear bioassay. These run to long columns (or several pages) of small print ordering the steroid universe from the aristocracy of Class 1 ("Supernovacort" 0.015%) down through the midrange ("Mediocricort" 0.026% ointment is Class 2, while Mediocricort 0.026% cream is only Class 3), down to the humble "Trivialicort" 32%, which on a good day is just a measly Class 6. All those multisyllabic names and numbers and classes bewilder and intimidate the poor kids. Even their earnest medical-student memorization skills leave them in despair of mastering all this stuff.

I ask them to ponder a mini-scenario: Your patient was given a topical steroid cream. He says it didn’t work. List all possible explanations.

The next day we discuss their answers. Most students manage to come up with several types of reasons. Maybe the steroid didn’t work because the diagnosis was wrong. (It was a fungus.) Perhaps the condition is inherently unresponsive (like knee psoriasis). Sometimes, the patient didn’t use the cream.

Then we break down that third category. Why would a patient not use the cream? Reasons include:

• The tube was too small (15 g for a full-body rash).

• The steroid did work, but the patient thought it didn’t because the eczema came back. (Eczema comes back.)

• The patient was afraid of steroids. ("I heard they thin your skin.")

I end our session by noting that this third group (the patient didn’t use the cream) is a) intellectually uninteresting; and b) the reason behind most cases were "the steroid didn’t work." By contrast, using the wrong steroid – as defined by the fine-grained distinctions on steroid potency tables – is rarely the difference between success and failure.

I give students a list of four generics, from weak to strong, and advise them not to clutter up their brains with any others. (Since most of them are headed for primary care, those four will be plenty, freeing brain space for board memorization.)

Ever since medical school, which is a rather long time ago by now, I’ve wondered why some things are taught and others left out. More particularly, why are some kinds of facts thought to be important (the ones you can quantify or put numbers next to, for instance) and others are too squishy to mention (such as knowing what the patient thinks about the treatment)?

After all, knowing what a patient thinks about what a treatment does – how it might harm them, and what a treatment "working" really means – has a lot to do with whether the treatment is used properly, or used at all. Why isn’t that important? Because you can’t put it into a table laced with decimal points and percentages?

The tendency to reduce everything to what you can measure has been around for a long time but seems to be getting worse. I read the other day about something called the Human Connectome Project, an effort to produce data to help answer the central question, "How do differences between you and me and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, and our experiences?"

I am not the first to wonder whether functional MRIs, with those gaily colored snapshots of the brain in action, really tell us more about how the brain works than does talking with the people who own those brains. The assumption seems to be that pictures of brain circuits are "real," whereas mere talk is mush, not the stuff of science, whose fruits we physicians are supposed to apply. I am wired, therefore I am.

Suppose a patient thinks that topical steroids thin the skin? Suppose she expects your eczema cream to make the rash go away once and for all, and when it comes back, she takes that as proof that it "didn’t work" and stops using it because it’s clearly worthless? Would those opinions show up on a color photo of her amygdala?

Can my patients be the only ones whose opinions about health and disease matter more, and more often, than do the tabulated measures of clinical efficacy?

You know, the real stuff you have to memorize and document, to get in and to get by.

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. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

My object all sublime

I shall achieve in time –

To let the punishment fit the crime –

The punishment fit the crime.

–The Mikado

Gilbert and Sullivan

The Mikado’s ambition to give back in a jocular, but apt, way to the subjects who annoyed him is well known. Although I am no Mikado and don’t give back to anybody, aptly or otherwise, I have to admit that the impulse to do so does cross my mind. Maybe it crosses yours, too. Here are some people I sometimes meet. You might recognize them, and perhaps approve some of my suggested just deserts; punishments that fit the crime (PTFTC).

• The imaginary voice mail. "Call John Doe back right away," reads the message. "Use this number."

"You have reached 617-555-1234. This voice-mailbox has not yet been set up and cannot accept calls. Goodbye."

PTFTC: New outgoing message: "Dr. Rockoff is not actually a dermatologist yet. He will get back to you as soon as he becomes one."

• Playing with a full box. "You have reached 617-555-4321. This mailbox is full and cannot accept messages. Goodbye."

PTFTC: Outgoing message: "You have reached the doctor’s office. The doctor has filled his monthly quota of advice giving. Please call back next month, preferably before the 9th."

• Never mind who this is. "Doctor, please call me back right away. My itch is terrible and the medicine you prescribed doesn’t work at all." Click.

PTFTC: Outgoing message: Heavy breathing for 30 seconds. (Has to be for everyone, since we don’t know the number to call.)

• Mumbles. "Doctor, zy... Zyglub ... really need frtunsn mnidioos ... You ... to dhrsrsrs ... 617-96dlubgx ... Again, the number is zigd ... 52879 ... cloy."

PTFTC: Outgoing message. "Hello, Zyg! Glub Dr. Roc ... Bfflp! Yucca grapetz! ... Brgl nice day!"

• The anonymous e-mailer. "Hi, Doc! That cream is great! Can you call more into my pharmacy? Thanks! Skip (championskateboarder360@gravlax.tv.)

PTFTC: Return e-mail: "Hey, Skip! Take care on that skateboard! Could I have your name? Thanks!"

• The mailed-scrip requester. "Please mail a prescription to Mr. Bean’s house," says the message. "It can’t be called or faxed in. It has to be mailed, with a 90-day supply and three refills."

PTFTC: "Dear Mr. Bean, Kindly send a detailed prescription request typed on an Underwood manual manufactured no later than 1936. Please include a stamped, self-addressed envelope with correct postage. Thank you."

• The walk-in scrip requester. "Doctor," says my front-desk person, catching me in the hall between patients. "Dimitriy is in the waiting room. He says he needs you to write out refills for the three medicines you gave him – the one for the scalp, the one for the body, and the one for the other part that he doesn’t want to tell me about. He says he’ll wait."

PTFTC: "Tell Dimitriy that I need to review his record in detail. I should be done first thing tomorrow morning."

• The highly-detailed-scrip requester. "Doctor, my insurer requires that my prescription be written in a specific way: ‘SuperDerm cream, six 45-gram tunes for a 90-day supply, apply twice a day, morning and night, substitution mandated on penalty of reporting to the Highest Authorities.’ After you’re done with that, I’ll instruct you on the correct way to write my three other prescriptions."

PTFTC: "Here are four blank prescription forms. Please fill them out exactly as your insurer requires. I will return in 21 minutes to review and sign them."

Turnabout is of course fair play. I am sure that many patients, mine and yours, could readily generate lists of our infractions along with appropriate penalties. For instance:

• The doctor kept me waiting so long that I got a parking ticket.

• He called in the solution when I specifically asked for the cream.

• I rearranged my whole schedule and hired a babysitter to keep my appointment, and then her office called the day before and canceled it.

To show my even-handedness, I have set up a Let-the-Punishment-Fit-the-Crime hotline for any patients reading this article. To take these calls, I have rented a special office just outside Fargo, North Dakota, at 701-555-6789, although I’m rarely there.

Oh yes, the voice mail hasn’t been set up yet.

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. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

My object all sublime

I shall achieve in time –

To let the punishment fit the crime –

The punishment fit the crime.

–The Mikado

Gilbert and Sullivan

The Mikado’s ambition to give back in a jocular, but apt, way to the subjects who annoyed him is well known. Although I am no Mikado and don’t give back to anybody, aptly or otherwise, I have to admit that the impulse to do so does cross my mind. Maybe it crosses yours, too. Here are some people I sometimes meet. You might recognize them, and perhaps approve some of my suggested just deserts; punishments that fit the crime (PTFTC).

• The imaginary voice mail. "Call John Doe back right away," reads the message. "Use this number."

"You have reached 617-555-1234. This voice-mailbox has not yet been set up and cannot accept calls. Goodbye."

PTFTC: New outgoing message: "Dr. Rockoff is not actually a dermatologist yet. He will get back to you as soon as he becomes one."

• Playing with a full box. "You have reached 617-555-4321. This mailbox is full and cannot accept messages. Goodbye."

PTFTC: Outgoing message: "You have reached the doctor’s office. The doctor has filled his monthly quota of advice giving. Please call back next month, preferably before the 9th."

• Never mind who this is. "Doctor, please call me back right away. My itch is terrible and the medicine you prescribed doesn’t work at all." Click.

PTFTC: Outgoing message: Heavy breathing for 30 seconds. (Has to be for everyone, since we don’t know the number to call.)

• Mumbles. "Doctor, zy... Zyglub ... really need frtunsn mnidioos ... You ... to dhrsrsrs ... 617-96dlubgx ... Again, the number is zigd ... 52879 ... cloy."

PTFTC: Outgoing message. "Hello, Zyg! Glub Dr. Roc ... Bfflp! Yucca grapetz! ... Brgl nice day!"

• The anonymous e-mailer. "Hi, Doc! That cream is great! Can you call more into my pharmacy? Thanks! Skip (championskateboarder360@gravlax.tv.)

PTFTC: Return e-mail: "Hey, Skip! Take care on that skateboard! Could I have your name? Thanks!"

• The mailed-scrip requester. "Please mail a prescription to Mr. Bean’s house," says the message. "It can’t be called or faxed in. It has to be mailed, with a 90-day supply and three refills."

PTFTC: "Dear Mr. Bean, Kindly send a detailed prescription request typed on an Underwood manual manufactured no later than 1936. Please include a stamped, self-addressed envelope with correct postage. Thank you."

• The walk-in scrip requester. "Doctor," says my front-desk person, catching me in the hall between patients. "Dimitriy is in the waiting room. He says he needs you to write out refills for the three medicines you gave him – the one for the scalp, the one for the body, and the one for the other part that he doesn’t want to tell me about. He says he’ll wait."

PTFTC: "Tell Dimitriy that I need to review his record in detail. I should be done first thing tomorrow morning."

• The highly-detailed-scrip requester. "Doctor, my insurer requires that my prescription be written in a specific way: ‘SuperDerm cream, six 45-gram tunes for a 90-day supply, apply twice a day, morning and night, substitution mandated on penalty of reporting to the Highest Authorities.’ After you’re done with that, I’ll instruct you on the correct way to write my three other prescriptions."

PTFTC: "Here are four blank prescription forms. Please fill them out exactly as your insurer requires. I will return in 21 minutes to review and sign them."

Turnabout is of course fair play. I am sure that many patients, mine and yours, could readily generate lists of our infractions along with appropriate penalties. For instance:

• The doctor kept me waiting so long that I got a parking ticket.

• He called in the solution when I specifically asked for the cream.

• I rearranged my whole schedule and hired a babysitter to keep my appointment, and then her office called the day before and canceled it.

To show my even-handedness, I have set up a Let-the-Punishment-Fit-the-Crime hotline for any patients reading this article. To take these calls, I have rented a special office just outside Fargo, North Dakota, at 701-555-6789, although I’m rarely there.

Oh yes, the voice mail hasn’t been set up yet.

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. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

My object all sublime

I shall achieve in time –

To let the punishment fit the crime –

The punishment fit the crime.

–The Mikado

Gilbert and Sullivan

The Mikado’s ambition to give back in a jocular, but apt, way to the subjects who annoyed him is well known. Although I am no Mikado and don’t give back to anybody, aptly or otherwise, I have to admit that the impulse to do so does cross my mind. Maybe it crosses yours, too. Here are some people I sometimes meet. You might recognize them, and perhaps approve some of my suggested just deserts; punishments that fit the crime (PTFTC).

• The imaginary voice mail. "Call John Doe back right away," reads the message. "Use this number."

"You have reached 617-555-1234. This voice-mailbox has not yet been set up and cannot accept calls. Goodbye."

PTFTC: New outgoing message: "Dr. Rockoff is not actually a dermatologist yet. He will get back to you as soon as he becomes one."

• Playing with a full box. "You have reached 617-555-4321. This mailbox is full and cannot accept messages. Goodbye."

PTFTC: Outgoing message: "You have reached the doctor’s office. The doctor has filled his monthly quota of advice giving. Please call back next month, preferably before the 9th."

• Never mind who this is. "Doctor, please call me back right away. My itch is terrible and the medicine you prescribed doesn’t work at all." Click.

PTFTC: Outgoing message: Heavy breathing for 30 seconds. (Has to be for everyone, since we don’t know the number to call.)

• Mumbles. "Doctor, zy... Zyglub ... really need frtunsn mnidioos ... You ... to dhrsrsrs ... 617-96dlubgx ... Again, the number is zigd ... 52879 ... cloy."

PTFTC: Outgoing message. "Hello, Zyg! Glub Dr. Roc ... Bfflp! Yucca grapetz! ... Brgl nice day!"

• The anonymous e-mailer. "Hi, Doc! That cream is great! Can you call more into my pharmacy? Thanks! Skip (championskateboarder360@gravlax.tv.)

PTFTC: Return e-mail: "Hey, Skip! Take care on that skateboard! Could I have your name? Thanks!"

• The mailed-scrip requester. "Please mail a prescription to Mr. Bean’s house," says the message. "It can’t be called or faxed in. It has to be mailed, with a 90-day supply and three refills."

PTFTC: "Dear Mr. Bean, Kindly send a detailed prescription request typed on an Underwood manual manufactured no later than 1936. Please include a stamped, self-addressed envelope with correct postage. Thank you."

• The walk-in scrip requester. "Doctor," says my front-desk person, catching me in the hall between patients. "Dimitriy is in the waiting room. He says he needs you to write out refills for the three medicines you gave him – the one for the scalp, the one for the body, and the one for the other part that he doesn’t want to tell me about. He says he’ll wait."

PTFTC: "Tell Dimitriy that I need to review his record in detail. I should be done first thing tomorrow morning."

• The highly-detailed-scrip requester. "Doctor, my insurer requires that my prescription be written in a specific way: ‘SuperDerm cream, six 45-gram tunes for a 90-day supply, apply twice a day, morning and night, substitution mandated on penalty of reporting to the Highest Authorities.’ After you’re done with that, I’ll instruct you on the correct way to write my three other prescriptions."

PTFTC: "Here are four blank prescription forms. Please fill them out exactly as your insurer requires. I will return in 21 minutes to review and sign them."

Turnabout is of course fair play. I am sure that many patients, mine and yours, could readily generate lists of our infractions along with appropriate penalties. For instance:

• The doctor kept me waiting so long that I got a parking ticket.

• He called in the solution when I specifically asked for the cream.

• I rearranged my whole schedule and hired a babysitter to keep my appointment, and then her office called the day before and canceled it.

To show my even-handedness, I have set up a Let-the-Punishment-Fit-the-Crime hotline for any patients reading this article. To take these calls, I have rented a special office just outside Fargo, North Dakota, at 701-555-6789, although I’m rarely there.

Oh yes, the voice mail hasn’t been set up yet.

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. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.