Under My Skin

The scenario was familiar. Henry looked peeved. Mary looked anxious. Henry spoke first.

"This spot on my nose has been there for months," he said. "I’m concerned because we’ll be in the sun in Aruba next week."

I examined Henry. "It’s not skin cancer," I said. "Just leave it alone, and it’ll be fine.

"Of course," I went on, "you’ll want to take sensible sun precautions while you’re on vacation, a hat, sunscreen, and so forth." That’s when Mary spoke up.

"You know, Doctor," she said, "Henry does not take sensible sun precautions."

"Yes I do!" Henry objected. "At 10 every morning I leave the beach ..." Mary interrupted him. "He abuses the sun, even though I remind him every day." You could tell by Henry’s hangdog expression that "every day" was no exaggeration.

In its many forms, the eternal battle of the sexes has been examined in countless books, plays, movies, and sitcoms. Gender stereotypes don’t tell the whole story, but without some truth they wouldn’t become stereotypes. There is no getting around the fact that men and women often have their own ways of looking at the world. One part of the world they see differently is health in general and skin health in particular.

I don’t know what life is like on other planets, but if it’s true that men are from Mars and women are from Venus, then it follows that:

• People on Venus follow instructions, eat right, and take care of things so they don’t get out of control. People on Mars can’t be bothered with stuff like that.

• People on Venus wash regularly and use good products. On Mars they don’t much care.

• Venusians moisturize and use sunscreen. Not Martians.

Mini-dramas like that of Henry and Mary play themselves out in our offices all the time. Women take health maintenance more seriously than men do (or than men like to pretend they do.) Proper face washing (in adolescents), regular mole checks (in adults), and careful sun care (especially among the older set) are common flashpoints of gender disagreement. By and large, women feel responsible to make sure men do the right thing, while men just want to be left alone. "I’m only here because..." says the man, but I cut him off. I know why he’s here. It’s just a question of which woman got him there. Real men, you see, don’t ask directions or visit doctors.

One of the right things that women feel obliged to encourage is moisturizing. Men are functional: We shop when we need something and we moisturize when we feel dry. Women think you should moisturize every day, regardless, to make skin healthier and ward off aging.

Maybe so, maybe not, but we men as a group really dislike the feel of lotions on our skin and resist applying them. We find the sensation unpleasant, and anyhow don’t get why we should bother in the first place. Women in turn can’t figure why men should be so cussedly defiant about doing what seems to them not just worthwhile but delightful.

Men, accompanied by women or sent in by them against their better judgment, often make a great show of being put upon. They shrug, roll their eyes, and look irritated, much as they did when they were 8 years old and their mother said, "Tell him, Doctor. Tell him to eat his vegetables. Tell him to wash his face." Now that he’s grown up, her plea is more likely to be, "Tell him, Doctor. Tell him he has to get his spots checked and put sunscreen on every day. Maybe he’ll listen to you. I tell him all the time but he never listens to me." When that happens, I try to split the difference when I can and let both parties save face. After all, they have to live with each other, not with me.

Besides, men’s little secret is that we expect the women in our lives to take care of us and make sure we do the right things that we can’t be bothered to do for ourselves. For many couples, that’s the unspoken deal. We men know it, but we keep it quiet, even from ourselves. Shh, don’t tell anybody ...

Besides, we don’t even have to ask directions anymore. We’ve got GPS!

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. Skin & Allergy News is a publication of Frontline Medical Communications.

The scenario was familiar. Henry looked peeved. Mary looked anxious. Henry spoke first.

"This spot on my nose has been there for months," he said. "I’m concerned because we’ll be in the sun in Aruba next week."

I examined Henry. "It’s not skin cancer," I said. "Just leave it alone, and it’ll be fine.

"Of course," I went on, "you’ll want to take sensible sun precautions while you’re on vacation, a hat, sunscreen, and so forth." That’s when Mary spoke up.

"You know, Doctor," she said, "Henry does not take sensible sun precautions."

"Yes I do!" Henry objected. "At 10 every morning I leave the beach ..." Mary interrupted him. "He abuses the sun, even though I remind him every day." You could tell by Henry’s hangdog expression that "every day" was no exaggeration.

In its many forms, the eternal battle of the sexes has been examined in countless books, plays, movies, and sitcoms. Gender stereotypes don’t tell the whole story, but without some truth they wouldn’t become stereotypes. There is no getting around the fact that men and women often have their own ways of looking at the world. One part of the world they see differently is health in general and skin health in particular.

I don’t know what life is like on other planets, but if it’s true that men are from Mars and women are from Venus, then it follows that:

• People on Venus follow instructions, eat right, and take care of things so they don’t get out of control. People on Mars can’t be bothered with stuff like that.

• People on Venus wash regularly and use good products. On Mars they don’t much care.

• Venusians moisturize and use sunscreen. Not Martians.

Mini-dramas like that of Henry and Mary play themselves out in our offices all the time. Women take health maintenance more seriously than men do (or than men like to pretend they do.) Proper face washing (in adolescents), regular mole checks (in adults), and careful sun care (especially among the older set) are common flashpoints of gender disagreement. By and large, women feel responsible to make sure men do the right thing, while men just want to be left alone. "I’m only here because..." says the man, but I cut him off. I know why he’s here. It’s just a question of which woman got him there. Real men, you see, don’t ask directions or visit doctors.

One of the right things that women feel obliged to encourage is moisturizing. Men are functional: We shop when we need something and we moisturize when we feel dry. Women think you should moisturize every day, regardless, to make skin healthier and ward off aging.

Maybe so, maybe not, but we men as a group really dislike the feel of lotions on our skin and resist applying them. We find the sensation unpleasant, and anyhow don’t get why we should bother in the first place. Women in turn can’t figure why men should be so cussedly defiant about doing what seems to them not just worthwhile but delightful.

Men, accompanied by women or sent in by them against their better judgment, often make a great show of being put upon. They shrug, roll their eyes, and look irritated, much as they did when they were 8 years old and their mother said, "Tell him, Doctor. Tell him to eat his vegetables. Tell him to wash his face." Now that he’s grown up, her plea is more likely to be, "Tell him, Doctor. Tell him he has to get his spots checked and put sunscreen on every day. Maybe he’ll listen to you. I tell him all the time but he never listens to me." When that happens, I try to split the difference when I can and let both parties save face. After all, they have to live with each other, not with me.

Besides, men’s little secret is that we expect the women in our lives to take care of us and make sure we do the right things that we can’t be bothered to do for ourselves. For many couples, that’s the unspoken deal. We men know it, but we keep it quiet, even from ourselves. Shh, don’t tell anybody ...

Besides, we don’t even have to ask directions anymore. We’ve got GPS!

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. Skin & Allergy News is a publication of Frontline Medical Communications.

The scenario was familiar. Henry looked peeved. Mary looked anxious. Henry spoke first.

"This spot on my nose has been there for months," he said. "I’m concerned because we’ll be in the sun in Aruba next week."

I examined Henry. "It’s not skin cancer," I said. "Just leave it alone, and it’ll be fine.

"Of course," I went on, "you’ll want to take sensible sun precautions while you’re on vacation, a hat, sunscreen, and so forth." That’s when Mary spoke up.

"You know, Doctor," she said, "Henry does not take sensible sun precautions."

"Yes I do!" Henry objected. "At 10 every morning I leave the beach ..." Mary interrupted him. "He abuses the sun, even though I remind him every day." You could tell by Henry’s hangdog expression that "every day" was no exaggeration.

In its many forms, the eternal battle of the sexes has been examined in countless books, plays, movies, and sitcoms. Gender stereotypes don’t tell the whole story, but without some truth they wouldn’t become stereotypes. There is no getting around the fact that men and women often have their own ways of looking at the world. One part of the world they see differently is health in general and skin health in particular.

I don’t know what life is like on other planets, but if it’s true that men are from Mars and women are from Venus, then it follows that:

• People on Venus follow instructions, eat right, and take care of things so they don’t get out of control. People on Mars can’t be bothered with stuff like that.

• People on Venus wash regularly and use good products. On Mars they don’t much care.

• Venusians moisturize and use sunscreen. Not Martians.

Mini-dramas like that of Henry and Mary play themselves out in our offices all the time. Women take health maintenance more seriously than men do (or than men like to pretend they do.) Proper face washing (in adolescents), regular mole checks (in adults), and careful sun care (especially among the older set) are common flashpoints of gender disagreement. By and large, women feel responsible to make sure men do the right thing, while men just want to be left alone. "I’m only here because..." says the man, but I cut him off. I know why he’s here. It’s just a question of which woman got him there. Real men, you see, don’t ask directions or visit doctors.

One of the right things that women feel obliged to encourage is moisturizing. Men are functional: We shop when we need something and we moisturize when we feel dry. Women think you should moisturize every day, regardless, to make skin healthier and ward off aging.

Maybe so, maybe not, but we men as a group really dislike the feel of lotions on our skin and resist applying them. We find the sensation unpleasant, and anyhow don’t get why we should bother in the first place. Women in turn can’t figure why men should be so cussedly defiant about doing what seems to them not just worthwhile but delightful.

Men, accompanied by women or sent in by them against their better judgment, often make a great show of being put upon. They shrug, roll their eyes, and look irritated, much as they did when they were 8 years old and their mother said, "Tell him, Doctor. Tell him to eat his vegetables. Tell him to wash his face." Now that he’s grown up, her plea is more likely to be, "Tell him, Doctor. Tell him he has to get his spots checked and put sunscreen on every day. Maybe he’ll listen to you. I tell him all the time but he never listens to me." When that happens, I try to split the difference when I can and let both parties save face. After all, they have to live with each other, not with me.

Besides, men’s little secret is that we expect the women in our lives to take care of us and make sure we do the right things that we can’t be bothered to do for ourselves. For many couples, that’s the unspoken deal. We men know it, but we keep it quiet, even from ourselves. Shh, don’t tell anybody ...

Besides, we don’t even have to ask directions anymore. We’ve got GPS!

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. Skin & Allergy News is a publication of Frontline Medical Communications.

If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.

They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.

Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.

What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.

Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.

I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.

We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.

"How’s your eczema been?" I asked.

"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."

Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.

Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.

I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.

Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "

I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.

"Went away," he said. "No problems anymore." I’d never have guessed.

What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.

So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.

There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.

Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.

Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.

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.

If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.

They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.

Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.

What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.

Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.

I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.

We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.

"How’s your eczema been?" I asked.

"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."

Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.

Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.

I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.

Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "

I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.

"Went away," he said. "No problems anymore." I’d never have guessed.

What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.

So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.

There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.

Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.

Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.

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.

If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.

They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.

Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.

What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.

Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.

I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.

We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.

"How’s your eczema been?" I asked.

"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."

Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.

Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.

I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.

Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "

I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.

"Went away," he said. "No problems anymore." I’d never have guessed.

What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.

So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.

There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.

Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.

Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.

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.

As the date for implementing ICD-10 gets closer, consulting firms send daily offers to help us adapt to the new diagnostic regime. As a service to the profession, Under My Skin will provide periodic updates to save you consulting fees.

In an earlier column, you learned about new codes like injury from burning water skis. We also covered codes for envenomation by Gila monsters, both unintentional and intentional. You should know that these are already available under ICD-9. No need to wait till next year to use them!

ICD-9-CM E905.0: Venomous snakes and lizards causing poisoning and toxic reactions. These include the following: cobra, copperhead snake, coral snake, fer-de-lance snake, Gila monster, krait, mamba, viper, and several others. Do NOT use this code for bites by nonvenomous snakes and lizards. (That may come back to bite you ... Sorry!)

Anyone who can define a fer-de-lance or a krait is gets extra credit (but no extra payment). If you can either identify a mamba, or dance it, good for you!

ICD-10 naturally amplifies this inadequate taxonomy:

• T63.111 – Toxic effect of venom of Gila monster, accidental (unintentional)

• T63.112 – Toxic effect of venom of Gila monster, intentional (self-harm)

• T63.113 – Toxic effect of venom of Gila monster, assault

• T63.114 – Toxic effect of venom of Gila monster, undetermined

Questions: For the new "assault" code, was the Gila monster the assailant or was its owner? Does "undetermined" mean you don’t really know how you got bitten (come on, was that really an accident – weren’t you petting the Gila kind of roughly?) or that you didn’t determine whether it actually was a Gila monster (because it ran away so fast that that it could have been a marmoset).

There are other ICD-9 codes you can already use (right now!) I recently got a 6-page EMR from a referring clinic (you get those, don’t you?) listing one of the patient’s 14 diagnoses as E968.2: Assault by striking by blunt or thrown object.

This opened my eyes to:

• E968.5 – Assault by transport vehicle.

• E968.3 – Assault by hot liquid.

• E968.1 – Assault by pushing from a high place. (Questions: How high? How hot? Transporting what?)

While on the subject of injuries in high places, you might consider:

• E840.1 – Accident by powered aircraft at takeoff or landing.

Again, ICD-10 will be more comprehensive.

Looking at injury from burning water skis, we find:

• V91.07 – Burn due to water-skis on fire.

Within which are:

• V91.07XA ... initial encounter.

• V91.07XD ... subsequent encounter.

• V91.07XS ... sequela.

This is not all! V91.07 has many other subcategories:

• V91.0 – Burn due to watercraft on fire.

• V91.01 – Burn due to passenger ship on fire.

• V91.02 – Burn due to fishing boat on fire.

• V91.05 – Burn due to canoe or kayak on fire.

But wait! There is also V91.1 – Crushed between watercraft and other watercraft or other object due to collision. Within which are:

• V91.10 – Crushed between merchant ship and other watercraft or other object due to collision.

• V91.12 – Crushed between fishing boat and other watercraft or other object due to collision.

• V91.15 – Crushed between canoe or kayak and other watercraft or other object due to collision.

Each of these of course includes subcodes for: initial encounter, subsequent encounter, and sequela. (Conversion hysteria caused by paranoid fear of rampaging kayaks?)

The practical advantages to learning all this extend beyond the office. Suppose you’re fishing in a rowboat on a lazy Sunday afternoon when a kayaker waving a flaming blowtorch careens toward you full tilt and you leap overboard. When the Coast Guard pulls you out, you can shout, "V91.05! V91.15!"

In our next installment, we will take up other subsets of external causes of morbidity, including:

• W20 – struck by thrown, projected, or falling object such as:

• W20.0 – Falling object in cave (initial encounter, subsequent encounter, sequela).

• W20.1 – Struck by object due to collapse of building (ditto).

• W28 – Contact with powered lawn mower.

• W60 – Contact with nonvenomous plant thorns and spines and sharp leaves.

Master these. Future columns will cover injuries caused by forces of nature, injuries caused by supernatural means (such as witchcraft, exorcism), assassination (first episode, second episode, sequela), and acute psychosis caused by marauding ICD-10 consultants.

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.

As the date for implementing ICD-10 gets closer, consulting firms send daily offers to help us adapt to the new diagnostic regime. As a service to the profession, Under My Skin will provide periodic updates to save you consulting fees.

In an earlier column, you learned about new codes like injury from burning water skis. We also covered codes for envenomation by Gila monsters, both unintentional and intentional. You should know that these are already available under ICD-9. No need to wait till next year to use them!

ICD-9-CM E905.0: Venomous snakes and lizards causing poisoning and toxic reactions. These include the following: cobra, copperhead snake, coral snake, fer-de-lance snake, Gila monster, krait, mamba, viper, and several others. Do NOT use this code for bites by nonvenomous snakes and lizards. (That may come back to bite you ... Sorry!)

Anyone who can define a fer-de-lance or a krait is gets extra credit (but no extra payment). If you can either identify a mamba, or dance it, good for you!

ICD-10 naturally amplifies this inadequate taxonomy:

• T63.111 – Toxic effect of venom of Gila monster, accidental (unintentional)

• T63.112 – Toxic effect of venom of Gila monster, intentional (self-harm)

• T63.113 – Toxic effect of venom of Gila monster, assault

• T63.114 – Toxic effect of venom of Gila monster, undetermined

Questions: For the new "assault" code, was the Gila monster the assailant or was its owner? Does "undetermined" mean you don’t really know how you got bitten (come on, was that really an accident – weren’t you petting the Gila kind of roughly?) or that you didn’t determine whether it actually was a Gila monster (because it ran away so fast that that it could have been a marmoset).

There are other ICD-9 codes you can already use (right now!) I recently got a 6-page EMR from a referring clinic (you get those, don’t you?) listing one of the patient’s 14 diagnoses as E968.2: Assault by striking by blunt or thrown object.

This opened my eyes to:

• E968.5 – Assault by transport vehicle.

• E968.3 – Assault by hot liquid.

• E968.1 – Assault by pushing from a high place. (Questions: How high? How hot? Transporting what?)

While on the subject of injuries in high places, you might consider:

• E840.1 – Accident by powered aircraft at takeoff or landing.

Again, ICD-10 will be more comprehensive.

Looking at injury from burning water skis, we find:

• V91.07 – Burn due to water-skis on fire.

Within which are:

• V91.07XA ... initial encounter.

• V91.07XD ... subsequent encounter.

• V91.07XS ... sequela.

This is not all! V91.07 has many other subcategories:

• V91.0 – Burn due to watercraft on fire.

• V91.01 – Burn due to passenger ship on fire.

• V91.02 – Burn due to fishing boat on fire.

• V91.05 – Burn due to canoe or kayak on fire.

But wait! There is also V91.1 – Crushed between watercraft and other watercraft or other object due to collision. Within which are:

• V91.10 – Crushed between merchant ship and other watercraft or other object due to collision.

• V91.12 – Crushed between fishing boat and other watercraft or other object due to collision.

• V91.15 – Crushed between canoe or kayak and other watercraft or other object due to collision.

Each of these of course includes subcodes for: initial encounter, subsequent encounter, and sequela. (Conversion hysteria caused by paranoid fear of rampaging kayaks?)

The practical advantages to learning all this extend beyond the office. Suppose you’re fishing in a rowboat on a lazy Sunday afternoon when a kayaker waving a flaming blowtorch careens toward you full tilt and you leap overboard. When the Coast Guard pulls you out, you can shout, "V91.05! V91.15!"

In our next installment, we will take up other subsets of external causes of morbidity, including:

• W20 – struck by thrown, projected, or falling object such as:

• W20.0 – Falling object in cave (initial encounter, subsequent encounter, sequela).

• W20.1 – Struck by object due to collapse of building (ditto).

• W28 – Contact with powered lawn mower.

• W60 – Contact with nonvenomous plant thorns and spines and sharp leaves.

Master these. Future columns will cover injuries caused by forces of nature, injuries caused by supernatural means (such as witchcraft, exorcism), assassination (first episode, second episode, sequela), and acute psychosis caused by marauding ICD-10 consultants.

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.

As the date for implementing ICD-10 gets closer, consulting firms send daily offers to help us adapt to the new diagnostic regime. As a service to the profession, Under My Skin will provide periodic updates to save you consulting fees.

In an earlier column, you learned about new codes like injury from burning water skis. We also covered codes for envenomation by Gila monsters, both unintentional and intentional. You should know that these are already available under ICD-9. No need to wait till next year to use them!

ICD-9-CM E905.0: Venomous snakes and lizards causing poisoning and toxic reactions. These include the following: cobra, copperhead snake, coral snake, fer-de-lance snake, Gila monster, krait, mamba, viper, and several others. Do NOT use this code for bites by nonvenomous snakes and lizards. (That may come back to bite you ... Sorry!)

Anyone who can define a fer-de-lance or a krait is gets extra credit (but no extra payment). If you can either identify a mamba, or dance it, good for you!

ICD-10 naturally amplifies this inadequate taxonomy:

• T63.111 – Toxic effect of venom of Gila monster, accidental (unintentional)

• T63.112 – Toxic effect of venom of Gila monster, intentional (self-harm)

• T63.113 – Toxic effect of venom of Gila monster, assault

• T63.114 – Toxic effect of venom of Gila monster, undetermined

Questions: For the new "assault" code, was the Gila monster the assailant or was its owner? Does "undetermined" mean you don’t really know how you got bitten (come on, was that really an accident – weren’t you petting the Gila kind of roughly?) or that you didn’t determine whether it actually was a Gila monster (because it ran away so fast that that it could have been a marmoset).

There are other ICD-9 codes you can already use (right now!) I recently got a 6-page EMR from a referring clinic (you get those, don’t you?) listing one of the patient’s 14 diagnoses as E968.2: Assault by striking by blunt or thrown object.

This opened my eyes to:

• E968.5 – Assault by transport vehicle.

• E968.3 – Assault by hot liquid.

• E968.1 – Assault by pushing from a high place. (Questions: How high? How hot? Transporting what?)

While on the subject of injuries in high places, you might consider:

• E840.1 – Accident by powered aircraft at takeoff or landing.

Again, ICD-10 will be more comprehensive.

Looking at injury from burning water skis, we find:

• V91.07 – Burn due to water-skis on fire.

Within which are:

• V91.07XA ... initial encounter.

• V91.07XD ... subsequent encounter.

• V91.07XS ... sequela.

This is not all! V91.07 has many other subcategories:

• V91.0 – Burn due to watercraft on fire.

• V91.01 – Burn due to passenger ship on fire.

• V91.02 – Burn due to fishing boat on fire.

• V91.05 – Burn due to canoe or kayak on fire.

But wait! There is also V91.1 – Crushed between watercraft and other watercraft or other object due to collision. Within which are:

• V91.10 – Crushed between merchant ship and other watercraft or other object due to collision.

• V91.12 – Crushed between fishing boat and other watercraft or other object due to collision.

• V91.15 – Crushed between canoe or kayak and other watercraft or other object due to collision.

Each of these of course includes subcodes for: initial encounter, subsequent encounter, and sequela. (Conversion hysteria caused by paranoid fear of rampaging kayaks?)

The practical advantages to learning all this extend beyond the office. Suppose you’re fishing in a rowboat on a lazy Sunday afternoon when a kayaker waving a flaming blowtorch careens toward you full tilt and you leap overboard. When the Coast Guard pulls you out, you can shout, "V91.05! V91.15!"

In our next installment, we will take up other subsets of external causes of morbidity, including:

• W20 – struck by thrown, projected, or falling object such as:

• W20.0 – Falling object in cave (initial encounter, subsequent encounter, sequela).

• W20.1 – Struck by object due to collapse of building (ditto).

• W28 – Contact with powered lawn mower.

• W60 – Contact with nonvenomous plant thorns and spines and sharp leaves.

Master these. Future columns will cover injuries caused by forces of nature, injuries caused by supernatural means (such as witchcraft, exorcism), assassination (first episode, second episode, sequela), and acute psychosis caused by marauding ICD-10 consultants.

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.

Six and a half years ago, my malpractice insurer made a payment to settle a case against a company I once ran in a neighboring state. Nine years before that, a physician who worked for me had lasered a tattoo on a woman’s ankle. She claimed it got infected and then scarred, but refused to be examined at that time, or later.

This case wound its way slowly through the system. I drove to the nearby state to plot strategy with the insurer’s attorney for dealing with the $50,000 claim. "I can’t understand why anyone would take a case this small," said the attorney.

When we got to the courthouse that January day, we saw why. The plaintiff – whom I had never met – was accompanied by a lawyer. He and my attorney met with the judge.

"Settle this case," she ordered.

And so we did, for $22,500. The plaintiff stipulated that I "did not act negligently in any respect."

As we exited the courtroom into the hall, the plaintiff approached me. "My tattoo isn’t gone yet," she said. "Would you be able to treat it?"

My attorney’s jaw dropped. Not mine, though. I had her put her ankle up on a bench to look at it. There was no scarring, just the hypopigmentation one sees after laser treatment in that area.

"You know," I told her. "I’m all the way in the next state. "The doctor here in town who treated you – the one who was going to testify against me today? He would be perfect."

We smiled at each other, shook hands, and I went home.

Fast forward to last week. A registered letter came to my office from a local electrical union. It contained a flyer that read:

Don’t be in the DARK about your doctor. XYZ hospital continues to allow doctors with recent malpractice payments to treat patients, WHY?

DR. ALAN S. ROCKOFF MADE A MALPRACTICE PAYMENT.

What kind of DOCTOR do you want treating you and your loved ones?

The accompanying letter explained that, "We intend to distribute [the leaflet] in the near future to anyone entering or leaving your medical building, as well as residents and businesses in the surrounding community. We will also be publicizing the content on DrRockoffexposed.com and through social media including Facebook and Twitter."

They added, "We strive for accuracy in all of our leaflets and websites." I was given 1 week to let them know if I found "anything untruthful or inaccurate," to "kindly let me know."

I thought the "kindly" was a nice touch.

The leaflet included a lot of nasty innuendoes about hospital XYZ, where I have staff privileges.

Bewildered, I contacted my malpractice insurer, who helpfully told me there was nothing I could do, and suggested I contact the hospital, at whom the campaign was clearly intended. I did so. The people at the hospital expressed sympathy and outrage about the union’s letter, and told me to ignore it.

An attorney affiliated with my malpractice insurer did some digging, and he sent me a link to an article showing that his union had used similar tactics against a hospital north of town 2 years ago. Their motive, it appears, is to be sure their union secures contracts for work at the hospitals in question.

In other words, friends, this is what is known in Mafia movies as a shakedown. "Nice medical staff you’ve got there," says the leaflet, in so many words. "Be a shame if anything happened to it."

As a kid, I used to watch Elliot Ness in "The Untouchables," but I never thought I would be personally involved in anything I saw there. But if you live long enough, you never know what you’ll experience. Anyhow, any publicity is good publicity, and DrRockoffexposed.com does spell my name right, even if it’s not nearly as fun to see as what one could imagine at something like www.TweetingCongressmanExposed.com.

For better or worse, the time when doctors sat in their offices, wrote notes on 3x5 cards, and collected cash payments they stowed in their desk drawers are long gone. In the Olympian corridors of power far above our heads, powerful forces that dictate our lives hurl thunderbolts at each other as they vie for money, power, and control. The trick is to stay out of their way and avoid becoming collateral damage.

Easy to say. Less easy to do.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

Six and a half years ago, my malpractice insurer made a payment to settle a case against a company I once ran in a neighboring state. Nine years before that, a physician who worked for me had lasered a tattoo on a woman’s ankle. She claimed it got infected and then scarred, but refused to be examined at that time, or later.

This case wound its way slowly through the system. I drove to the nearby state to plot strategy with the insurer’s attorney for dealing with the $50,000 claim. "I can’t understand why anyone would take a case this small," said the attorney.

When we got to the courthouse that January day, we saw why. The plaintiff – whom I had never met – was accompanied by a lawyer. He and my attorney met with the judge.

"Settle this case," she ordered.

And so we did, for $22,500. The plaintiff stipulated that I "did not act negligently in any respect."

As we exited the courtroom into the hall, the plaintiff approached me. "My tattoo isn’t gone yet," she said. "Would you be able to treat it?"

My attorney’s jaw dropped. Not mine, though. I had her put her ankle up on a bench to look at it. There was no scarring, just the hypopigmentation one sees after laser treatment in that area.

"You know," I told her. "I’m all the way in the next state. "The doctor here in town who treated you – the one who was going to testify against me today? He would be perfect."

We smiled at each other, shook hands, and I went home.

Fast forward to last week. A registered letter came to my office from a local electrical union. It contained a flyer that read:

Don’t be in the DARK about your doctor. XYZ hospital continues to allow doctors with recent malpractice payments to treat patients, WHY?

DR. ALAN S. ROCKOFF MADE A MALPRACTICE PAYMENT.

What kind of DOCTOR do you want treating you and your loved ones?

The accompanying letter explained that, "We intend to distribute [the leaflet] in the near future to anyone entering or leaving your medical building, as well as residents and businesses in the surrounding community. We will also be publicizing the content on DrRockoffexposed.com and through social media including Facebook and Twitter."

They added, "We strive for accuracy in all of our leaflets and websites." I was given 1 week to let them know if I found "anything untruthful or inaccurate," to "kindly let me know."

I thought the "kindly" was a nice touch.

The leaflet included a lot of nasty innuendoes about hospital XYZ, where I have staff privileges.

Bewildered, I contacted my malpractice insurer, who helpfully told me there was nothing I could do, and suggested I contact the hospital, at whom the campaign was clearly intended. I did so. The people at the hospital expressed sympathy and outrage about the union’s letter, and told me to ignore it.

An attorney affiliated with my malpractice insurer did some digging, and he sent me a link to an article showing that his union had used similar tactics against a hospital north of town 2 years ago. Their motive, it appears, is to be sure their union secures contracts for work at the hospitals in question.

In other words, friends, this is what is known in Mafia movies as a shakedown. "Nice medical staff you’ve got there," says the leaflet, in so many words. "Be a shame if anything happened to it."

As a kid, I used to watch Elliot Ness in "The Untouchables," but I never thought I would be personally involved in anything I saw there. But if you live long enough, you never know what you’ll experience. Anyhow, any publicity is good publicity, and DrRockoffexposed.com does spell my name right, even if it’s not nearly as fun to see as what one could imagine at something like www.TweetingCongressmanExposed.com.

For better or worse, the time when doctors sat in their offices, wrote notes on 3x5 cards, and collected cash payments they stowed in their desk drawers are long gone. In the Olympian corridors of power far above our heads, powerful forces that dictate our lives hurl thunderbolts at each other as they vie for money, power, and control. The trick is to stay out of their way and avoid becoming collateral damage.

Easy to say. Less easy to do.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

Six and a half years ago, my malpractice insurer made a payment to settle a case against a company I once ran in a neighboring state. Nine years before that, a physician who worked for me had lasered a tattoo on a woman’s ankle. She claimed it got infected and then scarred, but refused to be examined at that time, or later.

This case wound its way slowly through the system. I drove to the nearby state to plot strategy with the insurer’s attorney for dealing with the $50,000 claim. "I can’t understand why anyone would take a case this small," said the attorney.

When we got to the courthouse that January day, we saw why. The plaintiff – whom I had never met – was accompanied by a lawyer. He and my attorney met with the judge.

"Settle this case," she ordered.

And so we did, for $22,500. The plaintiff stipulated that I "did not act negligently in any respect."

As we exited the courtroom into the hall, the plaintiff approached me. "My tattoo isn’t gone yet," she said. "Would you be able to treat it?"

My attorney’s jaw dropped. Not mine, though. I had her put her ankle up on a bench to look at it. There was no scarring, just the hypopigmentation one sees after laser treatment in that area.

"You know," I told her. "I’m all the way in the next state. "The doctor here in town who treated you – the one who was going to testify against me today? He would be perfect."

We smiled at each other, shook hands, and I went home.

Fast forward to last week. A registered letter came to my office from a local electrical union. It contained a flyer that read:

Don’t be in the DARK about your doctor. XYZ hospital continues to allow doctors with recent malpractice payments to treat patients, WHY?

DR. ALAN S. ROCKOFF MADE A MALPRACTICE PAYMENT.

What kind of DOCTOR do you want treating you and your loved ones?

The accompanying letter explained that, "We intend to distribute [the leaflet] in the near future to anyone entering or leaving your medical building, as well as residents and businesses in the surrounding community. We will also be publicizing the content on DrRockoffexposed.com and through social media including Facebook and Twitter."

They added, "We strive for accuracy in all of our leaflets and websites." I was given 1 week to let them know if I found "anything untruthful or inaccurate," to "kindly let me know."

I thought the "kindly" was a nice touch.

The leaflet included a lot of nasty innuendoes about hospital XYZ, where I have staff privileges.

Bewildered, I contacted my malpractice insurer, who helpfully told me there was nothing I could do, and suggested I contact the hospital, at whom the campaign was clearly intended. I did so. The people at the hospital expressed sympathy and outrage about the union’s letter, and told me to ignore it.

An attorney affiliated with my malpractice insurer did some digging, and he sent me a link to an article showing that his union had used similar tactics against a hospital north of town 2 years ago. Their motive, it appears, is to be sure their union secures contracts for work at the hospitals in question.

In other words, friends, this is what is known in Mafia movies as a shakedown. "Nice medical staff you’ve got there," says the leaflet, in so many words. "Be a shame if anything happened to it."

As a kid, I used to watch Elliot Ness in "The Untouchables," but I never thought I would be personally involved in anything I saw there. But if you live long enough, you never know what you’ll experience. Anyhow, any publicity is good publicity, and DrRockoffexposed.com does spell my name right, even if it’s not nearly as fun to see as what one could imagine at something like www.TweetingCongressmanExposed.com.

For better or worse, the time when doctors sat in their offices, wrote notes on 3x5 cards, and collected cash payments they stowed in their desk drawers are long gone. In the Olympian corridors of power far above our heads, powerful forces that dictate our lives hurl thunderbolts at each other as they vie for money, power, and control. The trick is to stay out of their way and avoid becoming collateral damage.

Easy to say. Less easy to do.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

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.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

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.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

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.

"My friend took your elective," read the e-mail from Adam, a medical student I didn’t know. "I need one more rotation before I graduate and would love to get some dermatology experience, which I expect I’ll need for Family Medicine. Could you possibly accommodate me?"

Sure, no problem.

The day before he was to start, I e-mailed Adam with the time and place to show up, along with parking suggestions.

"Oh, sorry," came the reply. "I found another elective. Hope this causes no inconvenience."

Thanks, pal.

People, you may have noticed, are not always considerate. This includes patients. Take Irene. Please.

Irene is 28 years old. One of my associates diagnosed pyoderma and gave Irene oral antibiotics. She called Friday afternoon to report headaches and vomiting. Because of a scheduling mix-up, not one colleague – but both of them – thought they were covering and called her back. They each phoned Friday night and left messages on Irene’s home and cell numbers. And again on Saturday, twice each. Ditto on Sunday.

Irene finally did call back. Tuesday. She said she was fine.

Gee, thanks, Irene.

Or consider Zoe. Or more precisely, consider Zoe’s mother, Hildegard. Their family had just returned from Panama, a rain-forest jaunt being just the thing for a 2-year-old. Zoe had returned with a souvenir collection of bizarre, bull’s-eye–shaped plaques all over her face and torso. I had never seen anything like them. Perhaps bites? No one else in the travel party had them.

Because the child did not seem ill, I suggested to Hildegard that we spare Zoe a biopsy and see what happened over the next few days. I photographed the spots and said I would share the pictures with an academic specialist I know. Perhaps Hildegard would send me an e-mail update in 2 days? She would.

My academic friend looked at the photos and also had no idea. And from Hildegard? Radio silence. Was Zoe OK? Was she in an ICU?

I e-mailed Hildegard. No response. Not a good sign. I called and left a message, referring to the e-mail. No response. I wrote the referring pediatrician. No answer there either.

Three weeks later, Hortense, a nurse practitioner from the pediatrician’s office, came in as a patient. With some trepidation, I asked whether she was familiar with Zoe’s condition. She wasn’t. She would check and get back. She didn’t.

But I did, when I called Hortense a couple of days later with her own biopsy results. Had she perhaps checked on Zoe? Oh, right, she had. Zoe was fine. The spots had just gone away. Must have been bites or something.

Think I’ll just up my Valium.

Of course, more prosaic examples of this sort of thing happen all the time. Like the patient who calls for an emergency appointment. He has to come in. Right away.

"9:00 o’clock?" Not convenient. Staff meeting at work.

"2:00 o’clock?" Sorry, can’t make it then.

"5:30?" OK, I’ll be there! Thanks!

Then he doesn’t show. The rash went away. Or he got a better offer. Who knows?

After all these years, I should be used to this behavior by now, but sometimes, annoyance still gets the better of me. There are people – many, actually, and not just in the office – who really need you. Really, really. Their needs are urgent, overwhelming.

Your needs, less so.

There is no point in being cranky about this. We are in the people business, which means taking people as they come. It may mean following through when we worry about the consequences of not doing so, even if the patients themselves seem oblivious. It also means not taking it for granted when people do act with consideration.

Adam’s e-mail that he hoped I was not inconvenienced really steamed me. Then I thought, "I never met this guy, and I never will. He may find this kind of behavior unhelpful in his future professional dealings. But that will be his problem, won’t it?" So I decided not to respond.

Then I changed my mind.

"Inconvenience, no," I e-mailed back. "Inconsideration, for sure."

He apologized again, and I left it at that. There’s no emoticon for a Bronx cheer, anyway.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com.

"My friend took your elective," read the e-mail from Adam, a medical student I didn’t know. "I need one more rotation before I graduate and would love to get some dermatology experience, which I expect I’ll need for Family Medicine. Could you possibly accommodate me?"

Sure, no problem.

The day before he was to start, I e-mailed Adam with the time and place to show up, along with parking suggestions.

"Oh, sorry," came the reply. "I found another elective. Hope this causes no inconvenience."

Thanks, pal.

People, you may have noticed, are not always considerate. This includes patients. Take Irene. Please.

Irene is 28 years old. One of my associates diagnosed pyoderma and gave Irene oral antibiotics. She called Friday afternoon to report headaches and vomiting. Because of a scheduling mix-up, not one colleague – but both of them – thought they were covering and called her back. They each phoned Friday night and left messages on Irene’s home and cell numbers. And again on Saturday, twice each. Ditto on Sunday.

Irene finally did call back. Tuesday. She said she was fine.

Gee, thanks, Irene.

Or consider Zoe. Or more precisely, consider Zoe’s mother, Hildegard. Their family had just returned from Panama, a rain-forest jaunt being just the thing for a 2-year-old. Zoe had returned with a souvenir collection of bizarre, bull’s-eye–shaped plaques all over her face and torso. I had never seen anything like them. Perhaps bites? No one else in the travel party had them.

Because the child did not seem ill, I suggested to Hildegard that we spare Zoe a biopsy and see what happened over the next few days. I photographed the spots and said I would share the pictures with an academic specialist I know. Perhaps Hildegard would send me an e-mail update in 2 days? She would.

My academic friend looked at the photos and also had no idea. And from Hildegard? Radio silence. Was Zoe OK? Was she in an ICU?

I e-mailed Hildegard. No response. Not a good sign. I called and left a message, referring to the e-mail. No response. I wrote the referring pediatrician. No answer there either.

Three weeks later, Hortense, a nurse practitioner from the pediatrician’s office, came in as a patient. With some trepidation, I asked whether she was familiar with Zoe’s condition. She wasn’t. She would check and get back. She didn’t.

But I did, when I called Hortense a couple of days later with her own biopsy results. Had she perhaps checked on Zoe? Oh, right, she had. Zoe was fine. The spots had just gone away. Must have been bites or something.

Think I’ll just up my Valium.

Of course, more prosaic examples of this sort of thing happen all the time. Like the patient who calls for an emergency appointment. He has to come in. Right away.

"9:00 o’clock?" Not convenient. Staff meeting at work.

"2:00 o’clock?" Sorry, can’t make it then.

"5:30?" OK, I’ll be there! Thanks!

Then he doesn’t show. The rash went away. Or he got a better offer. Who knows?

After all these years, I should be used to this behavior by now, but sometimes, annoyance still gets the better of me. There are people – many, actually, and not just in the office – who really need you. Really, really. Their needs are urgent, overwhelming.

Your needs, less so.

There is no point in being cranky about this. We are in the people business, which means taking people as they come. It may mean following through when we worry about the consequences of not doing so, even if the patients themselves seem oblivious. It also means not taking it for granted when people do act with consideration.

Adam’s e-mail that he hoped I was not inconvenienced really steamed me. Then I thought, "I never met this guy, and I never will. He may find this kind of behavior unhelpful in his future professional dealings. But that will be his problem, won’t it?" So I decided not to respond.

Then I changed my mind.

"Inconvenience, no," I e-mailed back. "Inconsideration, for sure."

He apologized again, and I left it at that. There’s no emoticon for a Bronx cheer, anyway.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com.

"My friend took your elective," read the e-mail from Adam, a medical student I didn’t know. "I need one more rotation before I graduate and would love to get some dermatology experience, which I expect I’ll need for Family Medicine. Could you possibly accommodate me?"

Sure, no problem.

The day before he was to start, I e-mailed Adam with the time and place to show up, along with parking suggestions.

"Oh, sorry," came the reply. "I found another elective. Hope this causes no inconvenience."

Thanks, pal.

People, you may have noticed, are not always considerate. This includes patients. Take Irene. Please.

Irene is 28 years old. One of my associates diagnosed pyoderma and gave Irene oral antibiotics. She called Friday afternoon to report headaches and vomiting. Because of a scheduling mix-up, not one colleague – but both of them – thought they were covering and called her back. They each phoned Friday night and left messages on Irene’s home and cell numbers. And again on Saturday, twice each. Ditto on Sunday.

Irene finally did call back. Tuesday. She said she was fine.

Gee, thanks, Irene.

Or consider Zoe. Or more precisely, consider Zoe’s mother, Hildegard. Their family had just returned from Panama, a rain-forest jaunt being just the thing for a 2-year-old. Zoe had returned with a souvenir collection of bizarre, bull’s-eye–shaped plaques all over her face and torso. I had never seen anything like them. Perhaps bites? No one else in the travel party had them.

Because the child did not seem ill, I suggested to Hildegard that we spare Zoe a biopsy and see what happened over the next few days. I photographed the spots and said I would share the pictures with an academic specialist I know. Perhaps Hildegard would send me an e-mail update in 2 days? She would.

My academic friend looked at the photos and also had no idea. And from Hildegard? Radio silence. Was Zoe OK? Was she in an ICU?

I e-mailed Hildegard. No response. Not a good sign. I called and left a message, referring to the e-mail. No response. I wrote the referring pediatrician. No answer there either.

Three weeks later, Hortense, a nurse practitioner from the pediatrician’s office, came in as a patient. With some trepidation, I asked whether she was familiar with Zoe’s condition. She wasn’t. She would check and get back. She didn’t.

But I did, when I called Hortense a couple of days later with her own biopsy results. Had she perhaps checked on Zoe? Oh, right, she had. Zoe was fine. The spots had just gone away. Must have been bites or something.

Think I’ll just up my Valium.

Of course, more prosaic examples of this sort of thing happen all the time. Like the patient who calls for an emergency appointment. He has to come in. Right away.

"9:00 o’clock?" Not convenient. Staff meeting at work.

"2:00 o’clock?" Sorry, can’t make it then.

"5:30?" OK, I’ll be there! Thanks!

Then he doesn’t show. The rash went away. Or he got a better offer. Who knows?

After all these years, I should be used to this behavior by now, but sometimes, annoyance still gets the better of me. There are people – many, actually, and not just in the office – who really need you. Really, really. Their needs are urgent, overwhelming.

Your needs, less so.

There is no point in being cranky about this. We are in the people business, which means taking people as they come. It may mean following through when we worry about the consequences of not doing so, even if the patients themselves seem oblivious. It also means not taking it for granted when people do act with consideration.

Adam’s e-mail that he hoped I was not inconvenienced really steamed me. Then I thought, "I never met this guy, and I never will. He may find this kind of behavior unhelpful in his future professional dealings. But that will be his problem, won’t it?" So I decided not to respond.

Then I changed my mind.

"Inconvenience, no," I e-mailed back. "Inconsideration, for sure."

He apologized again, and I left it at that. There’s no emoticon for a Bronx cheer, anyway.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com.

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com.

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com.

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com.

Maybe it’s because spring is here and the flowers are blooming. Or it may be because my wife and I are marrying off our daughter this summer. (Why, thank you.) Whatever the reason, I thought I would share some of the ways my married patients met each other. When I ask couples how they got together, they are usually happy to tell me. Even after many years, most of them have no trouble remembering the particular circumstances of their introduction. They smile, and tell me a tale they have probably told many times. (Remember that this is a selected group – these couples are still together!)

Some of the stories are conventional – a mutual friend or family member fixed them up, or they met in high school or college. Nowadays, more and more are technological, though sometimes with a twist. ("I had so many bad experiences on EBliss4Ever.com that I was ready to give up. But then I decided to give it one more try – and got Stanley!") Sometimes, however, people share tales that sound too cute to be true, ones that even Hollywood script committees – lovers of the "cute-meet" – would reject as too schmaltzy and improbable to work in a romantic comedy. And yet, out here in real life, they somehow did.

"I met Lars in a bar," says Bridget. "My friend Susie and I were having a beer, and I decided to stand up and move to another table. Lars is a large person, and he was walking by just when I got up. I turned to my left- – and hit him right in the chest with my glass. The beer splashed all over him and made a real mess. It took a long time to clean up."

"Oh come on. Did that really happen?"

"Absolutely! We were married a year ago."

Then there is Shane Walsh, who tells me not about himself but about his sister. "We’re a close-knit Irish family," he says. "Five boys and a girl. We were very protective of our sister and made sure that the guys she went out with were the right sort. Then she met the man who’s now her husband, and we all agree that he’s terrific. His name is also Walsh."

"In fact, that’s how they met," Shane says. "They were both at a party, when a guy across the room called out, ‘Hey, Walshie!’ "

"Both of them turned around at the same time and saw each other. The rest is history."

The luck of the Irish, I guess.

My last tale concerns an older pair, Gregory and Kate, married 39 years. They remember their first meeting very fondly.

"We both belonged to an apple-picking club," recalls Kate. "That fall weekend the whole group traveled by bus up to Maine. It was raining and miserable. When we got to the farm, the lady handing out the collecting baskets said, ‘You’re not from around here, are you?’ She meant that anybody local would have too much sense to pick apples in the driving rain."

"We were standing near each other under the same tree," said Gregory. "It was just like ..."

"Wait a minute," I interrupt, "you don’t mean ..."

"Yes indeed," says Greg, with a twinkle. "She handed me an apple." Kate laughs in agreement.

There you have it – life imitating Scripture. Although there’s nothing in the Good Book about Adam and Eve hiding under the Tree of Knowledge to keep from getting wet.

Here’s to happy endings, however they start out.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com. 

Maybe it’s because spring is here and the flowers are blooming. Or it may be because my wife and I are marrying off our daughter this summer. (Why, thank you.) Whatever the reason, I thought I would share some of the ways my married patients met each other. When I ask couples how they got together, they are usually happy to tell me. Even after many years, most of them have no trouble remembering the particular circumstances of their introduction. They smile, and tell me a tale they have probably told many times. (Remember that this is a selected group – these couples are still together!)

Some of the stories are conventional – a mutual friend or family member fixed them up, or they met in high school or college. Nowadays, more and more are technological, though sometimes with a twist. ("I had so many bad experiences on EBliss4Ever.com that I was ready to give up. But then I decided to give it one more try – and got Stanley!") Sometimes, however, people share tales that sound too cute to be true, ones that even Hollywood script committees – lovers of the "cute-meet" – would reject as too schmaltzy and improbable to work in a romantic comedy. And yet, out here in real life, they somehow did.

"I met Lars in a bar," says Bridget. "My friend Susie and I were having a beer, and I decided to stand up and move to another table. Lars is a large person, and he was walking by just when I got up. I turned to my left- – and hit him right in the chest with my glass. The beer splashed all over him and made a real mess. It took a long time to clean up."

"Oh come on. Did that really happen?"

"Absolutely! We were married a year ago."

Then there is Shane Walsh, who tells me not about himself but about his sister. "We’re a close-knit Irish family," he says. "Five boys and a girl. We were very protective of our sister and made sure that the guys she went out with were the right sort. Then she met the man who’s now her husband, and we all agree that he’s terrific. His name is also Walsh."

"In fact, that’s how they met," Shane says. "They were both at a party, when a guy across the room called out, ‘Hey, Walshie!’ "

"Both of them turned around at the same time and saw each other. The rest is history."

The luck of the Irish, I guess.

My last tale concerns an older pair, Gregory and Kate, married 39 years. They remember their first meeting very fondly.

"We both belonged to an apple-picking club," recalls Kate. "That fall weekend the whole group traveled by bus up to Maine. It was raining and miserable. When we got to the farm, the lady handing out the collecting baskets said, ‘You’re not from around here, are you?’ She meant that anybody local would have too much sense to pick apples in the driving rain."

"We were standing near each other under the same tree," said Gregory. "It was just like ..."

"Wait a minute," I interrupt, "you don’t mean ..."

"Yes indeed," says Greg, with a twinkle. "She handed me an apple." Kate laughs in agreement.

There you have it – life imitating Scripture. Although there’s nothing in the Good Book about Adam and Eve hiding under the Tree of Knowledge to keep from getting wet.

Here’s to happy endings, however they start out.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com. 

Maybe it’s because spring is here and the flowers are blooming. Or it may be because my wife and I are marrying off our daughter this summer. (Why, thank you.) Whatever the reason, I thought I would share some of the ways my married patients met each other. When I ask couples how they got together, they are usually happy to tell me. Even after many years, most of them have no trouble remembering the particular circumstances of their introduction. They smile, and tell me a tale they have probably told many times. (Remember that this is a selected group – these couples are still together!)

Some of the stories are conventional – a mutual friend or family member fixed them up, or they met in high school or college. Nowadays, more and more are technological, though sometimes with a twist. ("I had so many bad experiences on EBliss4Ever.com that I was ready to give up. But then I decided to give it one more try – and got Stanley!") Sometimes, however, people share tales that sound too cute to be true, ones that even Hollywood script committees – lovers of the "cute-meet" – would reject as too schmaltzy and improbable to work in a romantic comedy. And yet, out here in real life, they somehow did.

"I met Lars in a bar," says Bridget. "My friend Susie and I were having a beer, and I decided to stand up and move to another table. Lars is a large person, and he was walking by just when I got up. I turned to my left- – and hit him right in the chest with my glass. The beer splashed all over him and made a real mess. It took a long time to clean up."

"Oh come on. Did that really happen?"

"Absolutely! We were married a year ago."

Then there is Shane Walsh, who tells me not about himself but about his sister. "We’re a close-knit Irish family," he says. "Five boys and a girl. We were very protective of our sister and made sure that the guys she went out with were the right sort. Then she met the man who’s now her husband, and we all agree that he’s terrific. His name is also Walsh."

"In fact, that’s how they met," Shane says. "They were both at a party, when a guy across the room called out, ‘Hey, Walshie!’ "

"Both of them turned around at the same time and saw each other. The rest is history."

The luck of the Irish, I guess.

My last tale concerns an older pair, Gregory and Kate, married 39 years. They remember their first meeting very fondly.

"We both belonged to an apple-picking club," recalls Kate. "That fall weekend the whole group traveled by bus up to Maine. It was raining and miserable. When we got to the farm, the lady handing out the collecting baskets said, ‘You’re not from around here, are you?’ She meant that anybody local would have too much sense to pick apples in the driving rain."

"We were standing near each other under the same tree," said Gregory. "It was just like ..."

"Wait a minute," I interrupt, "you don’t mean ..."

"Yes indeed," says Greg, with a twinkle. "She handed me an apple." Kate laughs in agreement.

There you have it – life imitating Scripture. Although there’s nothing in the Good Book about Adam and Eve hiding under the Tree of Knowledge to keep from getting wet.

Here’s to happy endings, however they start out.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at sknews@frontlinemedcom.com. 

"How have you been treating this?" I asked Ivan. He had a rash on his shin.

"Plantain leaves," he explained.

Plantains, of course. Fry ’em or apply ’em.

Home remedies have always intrigued me. Take Preparation H ointment. Good for bags under the eyes, they say. Also good for hemorrhoids. Really good for people who have trouble telling the difference.

Or tea tree oil. I’ve heard about that for years, but never took the time to find out what a tea tree is. A tree shaped like a "T"? A tree that grows tea? A tree made out of tea?

Turns out it is Melaleuca alternifolia, a source of traditional remedies among the indigenous Bundjalung people of Eastern Australia. (Thank you, Wikipedia.) It may kill viruses, bacteria, and fungi. And it makes a dandy shampoo.

Got poison ivy? Try jewelweed (if you can find it). Or rat vein tea (not sure I want to find that). Or boiled sweet fern. Or (of course) tea tree oil.

Do home remedies work? Truth be told, I don’t claim to know one way or the other. Anyhow, I find a different question more interesting – not whether home remedies work, but why people think they do.

The answer to that seems straightforward. People think home remedies work because other people say so. Vicks VapoRub ointment for toenail fungus? Hank says it cleared him right up! His buddy, Frankie, on the other hand, swears by apple cider vinegar for his own toenails. He’s also sure it got rid of Frankie Jr.’s head lice, although back at school, other kids complained that Frankie Jr. smelled like a salad. And his wife Franchette uses it to help reverse the signs of aging.

Which points to something about the popularity of home remedies: There is a big difference between the way patients think and the way doctors do. Many of these cures – most nowadays are either traditional, natural, or both – are supposed to be good for ... well, just about anything. The list of uses for plantains, for instance, includes rashes, wounds, ulcerations, cuts, swelling, sprains, bruises, burns, eczema, cracked lips, poison ivy, mosquito bites, diaper rash, boils, hemorrhoids, blisters, snake bites, spider bites, splinters, and thorns.

Or take another popular item, jojoba oil (that’s ho-HO-ba to you). Named by the Tohono O’odham people of the Sonoran desert (repositories of ancient wisdom, presumably), jojoba is recommended for the treatment of wrinkles; hair loss; joint pain; hemorrhoids (take note, Preparation H nonresponders!); smoker’s cough; and constipation. It also lubricates locks and engines, and it is good for covering homemade cucumbers. Look it up.

Lists like these might make a physician skeptical, prone to wonder which mechanism of action could possibly explain such disparate effects and what studies could be designed to support or refute them. Considerations like these do not generally trouble patients. If something is good, well, it’s just good, for one thing or for many. Doctors split. Patients lump.

I thought I’d heard every folk remedy there is, earnest or whimsical, until Tibor came by last month. A well-spoken gent with a thick, Hungarian accent, Tibor pulled up his shirt and showed me a lot of eczema.

"Two things make it better," he explained. "The first thing, I swim every day in a chlorinated pool to cool it off."

That was a surprise, considering how many eczema patients are convinced that chlorine makes them worse.

And the second?

"Yogurt," he said. "I put on nonfat yogurt." But not just any nonfat yogurt.

"I tried all different kinds," Tibor went on. "I tried flavored yogurt, I tried Greek yogurt. But the best is plain nonfat yogurt."

A controlled experiment!

I asked Tibor where he got the idea for applying yogurt to his rash.

"My mother suggested some kind of peasant remedy when I was a kid," he said. "It may have been sour cream."

So it was some kind of rash, treated with something dairy. I tried to picture little Tibor covered with sour cream. I couldn’t.

"I put the yogurt on last night," said Tibor, proudly rolling up his sleeve to show me an almost eczema-free arm. "See how well it works!"

Anecdotal, perhaps, but still impressive. It cures eczema! It lowers cholesterol! It’s on sale!

Take that, tea tree oil.

Dr. Rockoff practices dermatology in Brookline, Mass.

"How have you been treating this?" I asked Ivan. He had a rash on his shin.

"Plantain leaves," he explained.

Plantains, of course. Fry ’em or apply ’em.

Home remedies have always intrigued me. Take Preparation H ointment. Good for bags under the eyes, they say. Also good for hemorrhoids. Really good for people who have trouble telling the difference.

Or tea tree oil. I’ve heard about that for years, but never took the time to find out what a tea tree is. A tree shaped like a "T"? A tree that grows tea? A tree made out of tea?

Turns out it is Melaleuca alternifolia, a source of traditional remedies among the indigenous Bundjalung people of Eastern Australia. (Thank you, Wikipedia.) It may kill viruses, bacteria, and fungi. And it makes a dandy shampoo.

Got poison ivy? Try jewelweed (if you can find it). Or rat vein tea (not sure I want to find that). Or boiled sweet fern. Or (of course) tea tree oil.

Do home remedies work? Truth be told, I don’t claim to know one way or the other. Anyhow, I find a different question more interesting – not whether home remedies work, but why people think they do.

The answer to that seems straightforward. People think home remedies work because other people say so. Vicks VapoRub ointment for toenail fungus? Hank says it cleared him right up! His buddy, Frankie, on the other hand, swears by apple cider vinegar for his own toenails. He’s also sure it got rid of Frankie Jr.’s head lice, although back at school, other kids complained that Frankie Jr. smelled like a salad. And his wife Franchette uses it to help reverse the signs of aging.

Which points to something about the popularity of home remedies: There is a big difference between the way patients think and the way doctors do. Many of these cures – most nowadays are either traditional, natural, or both – are supposed to be good for ... well, just about anything. The list of uses for plantains, for instance, includes rashes, wounds, ulcerations, cuts, swelling, sprains, bruises, burns, eczema, cracked lips, poison ivy, mosquito bites, diaper rash, boils, hemorrhoids, blisters, snake bites, spider bites, splinters, and thorns.

Or take another popular item, jojoba oil (that’s ho-HO-ba to you). Named by the Tohono O’odham people of the Sonoran desert (repositories of ancient wisdom, presumably), jojoba is recommended for the treatment of wrinkles; hair loss; joint pain; hemorrhoids (take note, Preparation H nonresponders!); smoker’s cough; and constipation. It also lubricates locks and engines, and it is good for covering homemade cucumbers. Look it up.

Lists like these might make a physician skeptical, prone to wonder which mechanism of action could possibly explain such disparate effects and what studies could be designed to support or refute them. Considerations like these do not generally trouble patients. If something is good, well, it’s just good, for one thing or for many. Doctors split. Patients lump.

I thought I’d heard every folk remedy there is, earnest or whimsical, until Tibor came by last month. A well-spoken gent with a thick, Hungarian accent, Tibor pulled up his shirt and showed me a lot of eczema.

"Two things make it better," he explained. "The first thing, I swim every day in a chlorinated pool to cool it off."

That was a surprise, considering how many eczema patients are convinced that chlorine makes them worse.

And the second?

"Yogurt," he said. "I put on nonfat yogurt." But not just any nonfat yogurt.

"I tried all different kinds," Tibor went on. "I tried flavored yogurt, I tried Greek yogurt. But the best is plain nonfat yogurt."

A controlled experiment!

I asked Tibor where he got the idea for applying yogurt to his rash.

"My mother suggested some kind of peasant remedy when I was a kid," he said. "It may have been sour cream."

So it was some kind of rash, treated with something dairy. I tried to picture little Tibor covered with sour cream. I couldn’t.

"I put the yogurt on last night," said Tibor, proudly rolling up his sleeve to show me an almost eczema-free arm. "See how well it works!"

Anecdotal, perhaps, but still impressive. It cures eczema! It lowers cholesterol! It’s on sale!

Take that, tea tree oil.

Dr. Rockoff practices dermatology in Brookline, Mass.

"How have you been treating this?" I asked Ivan. He had a rash on his shin.

"Plantain leaves," he explained.

Plantains, of course. Fry ’em or apply ’em.

Home remedies have always intrigued me. Take Preparation H ointment. Good for bags under the eyes, they say. Also good for hemorrhoids. Really good for people who have trouble telling the difference.

Or tea tree oil. I’ve heard about that for years, but never took the time to find out what a tea tree is. A tree shaped like a "T"? A tree that grows tea? A tree made out of tea?

Turns out it is Melaleuca alternifolia, a source of traditional remedies among the indigenous Bundjalung people of Eastern Australia. (Thank you, Wikipedia.) It may kill viruses, bacteria, and fungi. And it makes a dandy shampoo.

Got poison ivy? Try jewelweed (if you can find it). Or rat vein tea (not sure I want to find that). Or boiled sweet fern. Or (of course) tea tree oil.

Do home remedies work? Truth be told, I don’t claim to know one way or the other. Anyhow, I find a different question more interesting – not whether home remedies work, but why people think they do.

The answer to that seems straightforward. People think home remedies work because other people say so. Vicks VapoRub ointment for toenail fungus? Hank says it cleared him right up! His buddy, Frankie, on the other hand, swears by apple cider vinegar for his own toenails. He’s also sure it got rid of Frankie Jr.’s head lice, although back at school, other kids complained that Frankie Jr. smelled like a salad. And his wife Franchette uses it to help reverse the signs of aging.

Which points to something about the popularity of home remedies: There is a big difference between the way patients think and the way doctors do. Many of these cures – most nowadays are either traditional, natural, or both – are supposed to be good for ... well, just about anything. The list of uses for plantains, for instance, includes rashes, wounds, ulcerations, cuts, swelling, sprains, bruises, burns, eczema, cracked lips, poison ivy, mosquito bites, diaper rash, boils, hemorrhoids, blisters, snake bites, spider bites, splinters, and thorns.

Or take another popular item, jojoba oil (that’s ho-HO-ba to you). Named by the Tohono O’odham people of the Sonoran desert (repositories of ancient wisdom, presumably), jojoba is recommended for the treatment of wrinkles; hair loss; joint pain; hemorrhoids (take note, Preparation H nonresponders!); smoker’s cough; and constipation. It also lubricates locks and engines, and it is good for covering homemade cucumbers. Look it up.

Lists like these might make a physician skeptical, prone to wonder which mechanism of action could possibly explain such disparate effects and what studies could be designed to support or refute them. Considerations like these do not generally trouble patients. If something is good, well, it’s just good, for one thing or for many. Doctors split. Patients lump.

I thought I’d heard every folk remedy there is, earnest or whimsical, until Tibor came by last month. A well-spoken gent with a thick, Hungarian accent, Tibor pulled up his shirt and showed me a lot of eczema.

"Two things make it better," he explained. "The first thing, I swim every day in a chlorinated pool to cool it off."

That was a surprise, considering how many eczema patients are convinced that chlorine makes them worse.

And the second?

"Yogurt," he said. "I put on nonfat yogurt." But not just any nonfat yogurt.

"I tried all different kinds," Tibor went on. "I tried flavored yogurt, I tried Greek yogurt. But the best is plain nonfat yogurt."

A controlled experiment!

I asked Tibor where he got the idea for applying yogurt to his rash.

"My mother suggested some kind of peasant remedy when I was a kid," he said. "It may have been sour cream."

So it was some kind of rash, treated with something dairy. I tried to picture little Tibor covered with sour cream. I couldn’t.

"I put the yogurt on last night," said Tibor, proudly rolling up his sleeve to show me an almost eczema-free arm. "See how well it works!"

Anecdotal, perhaps, but still impressive. It cures eczema! It lowers cholesterol! It’s on sale!

Take that, tea tree oil.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.