Alan Rockoff

I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”

“No, it won't scar or leave a hole.”

“Will it leave a scar or a hole?”

“No. No scar or hole.”

“Will it leave a scar or a hole?”

“No scar. No hole.”

Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.

Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.

Anxiety is a great promoter of obsession.

“This spot is changing. Is it cancer?”

“No, it isn't cancer.”

“It's not cancer?”

“It's not cancer.”

“Are you sure it's not cancer?”

By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.

Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.

“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”

“No, Ma, just on this one.”

“Why not take off your other shoe, just to check.”

“There aren't any on the other foot. I looked.”

“We're at the doctor's. Let's take a look, to be sure.”

“Ma!”

Some day Samantha will get her chance to pay this forward.

Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.

Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”

Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.

“It's on my back somewhere.”

“Let's see. I'm looking at your whole back, and everything looks fine.”

“But wait, it's here somewhere. …”

If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:

“I'm looking at it. … I can see it. … And it's okay.”

Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)

Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.

Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.

When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.

Ah, blessed relief.

Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.

That's what I think, anyhow.

So what do you think?

So what do you think?

So what do you think?

I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”

“No, it won't scar or leave a hole.”

“Will it leave a scar or a hole?”

“No. No scar or hole.”

“Will it leave a scar or a hole?”

“No scar. No hole.”

Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.

Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.

Anxiety is a great promoter of obsession.

“This spot is changing. Is it cancer?”

“No, it isn't cancer.”

“It's not cancer?”

“It's not cancer.”

“Are you sure it's not cancer?”

By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.

Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.

“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”

“No, Ma, just on this one.”

“Why not take off your other shoe, just to check.”

“There aren't any on the other foot. I looked.”

“We're at the doctor's. Let's take a look, to be sure.”

“Ma!”

Some day Samantha will get her chance to pay this forward.

Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.

Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”

Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.

“It's on my back somewhere.”

“Let's see. I'm looking at your whole back, and everything looks fine.”

“But wait, it's here somewhere. …”

If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:

“I'm looking at it. … I can see it. … And it's okay.”

Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)

Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.

Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.

When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.

Ah, blessed relief.

Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.

That's what I think, anyhow.

So what do you think?

So what do you think?

So what do you think?

I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”

“No, it won't scar or leave a hole.”

“Will it leave a scar or a hole?”

“No. No scar or hole.”

“Will it leave a scar or a hole?”

“No scar. No hole.”

Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.

Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.

Anxiety is a great promoter of obsession.

“This spot is changing. Is it cancer?”

“No, it isn't cancer.”

“It's not cancer?”

“It's not cancer.”

“Are you sure it's not cancer?”

By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.

Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.

“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”

“No, Ma, just on this one.”

“Why not take off your other shoe, just to check.”

“There aren't any on the other foot. I looked.”

“We're at the doctor's. Let's take a look, to be sure.”

“Ma!”

Some day Samantha will get her chance to pay this forward.

Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.

Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”

Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.

“It's on my back somewhere.”

“Let's see. I'm looking at your whole back, and everything looks fine.”

“But wait, it's here somewhere. …”

If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:

“I'm looking at it. … I can see it. … And it's okay.”

Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)

Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.

Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.

When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.

Ah, blessed relief.

Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.

That's what I think, anyhow.

So what do you think?

So what do you think?

So what do you think?

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

“I found you on Yelp,” said Erica. “You had the second most reviews.”

“Saw Dr. Rockoff and was extremely disappointed. … The first time I visited, I was put on a very aggressive treatment plan which ended up not helping my skin problems. When I went back for a follow up, he recommended the same products insisting that I had not tried them yet … when he himself had prescribed them to me 2 months earlier!” Kristen Z.

I looked at Kristen's chart. The “very aggressive” plan was benzoyl peroxide, clindamycin gel, and minocycline. She had used doxycycline, tretinoin, and adapalene for years. At her return visit, I added tazarotene. A month later, she called for refills.

Pretty sharp and accurate review, yes?

Other notices were more favorable. Here's one:

“I go to the Rockoff Center for all my facial needs. This is a dermatologist office, so it is much better than going to a spa.”

So, I guess all that medical school was worth it after all.

But Yelp doesn't limit itself to dermatologists, or even to physicians. You can also read reviews of restaurants, shopping, nightlife, and beauty and spas. In the last category, here's one for a tattoo parlor: “I was so happy with how it came out. It is really simple, just tracing my handwriting, but every day I am amazed at how authentic it looks!”

Sites like Yelp represent a larger cultural trend fostered by the Internet, which lets anyone anywhere say anything to everyone everywhere. In this respect, the Internet is a great leveler that sweeps away rank and privilege and lets professors and peons alike hold forth on history, medicine, or fast-food joints. Those who choose to can show the universe their picture; share their birthdays, hobbies, and preferences; and let the world read more about them.

The effects of this trend are still evolving, but they are likely to be profound and may have increasing relevance to physicians. Consumer Aware and Blue Cross Blue Shield of Minnesota have set up a Yelp-like site, www.thehealthcarescoop.com

“My daughter died of heart failure at the [XYZ] Heart Hospital. [She] had an aortic valve replacement. … She was 28 when she went in for her aftercare checkup with the surgeon, she died a day later in the hospital. The medical team assigned to her, as well as her surgeon, did not respond with any urgency even though there was an infection present, she was given no antibiotics. … Hindsight tells me that she would be alive today had the proper care been taken at the time she came in for her aftercare checkup.”

Here's another: “My wife was scheduled for her first colonoscopy so she was naturally nervous. The staff at the [ABC] Clinic made her feel very comfortable. They were very attentive during the recovery time and even followed up with a 'check-in' phone call after the procedure to see how she was doing. The [ABC] Clinic is great.”

Is XYZ Heart Hospital incompetent? Is ABC Clinic superb? “Reviews” like these give us no real idea. Those who write them are, of course, entitled to their opinions, and the nature of such opinions give us insight into the way real people—our patients—talk about us to their friends and family and judge how we've done.

But should society rate us on the basis of reviews of this kind? Will this become yet another flawed criterion that health insurers will use to implement pay for performance?

Maybe we should call our leaders and professional societies and do some yelping ourselves.

“I found you on Yelp,” said Erica. “You had the second most reviews.”

“Saw Dr. Rockoff and was extremely disappointed. … The first time I visited, I was put on a very aggressive treatment plan which ended up not helping my skin problems. When I went back for a follow up, he recommended the same products insisting that I had not tried them yet … when he himself had prescribed them to me 2 months earlier!” Kristen Z.

I looked at Kristen's chart. The “very aggressive” plan was benzoyl peroxide, clindamycin gel, and minocycline. She had used doxycycline, tretinoin, and adapalene for years. At her return visit, I added tazarotene. A month later, she called for refills.

Pretty sharp and accurate review, yes?

Other notices were more favorable. Here's one:

“I go to the Rockoff Center for all my facial needs. This is a dermatologist office, so it is much better than going to a spa.”

So, I guess all that medical school was worth it after all.

But Yelp doesn't limit itself to dermatologists, or even to physicians. You can also read reviews of restaurants, shopping, nightlife, and beauty and spas. In the last category, here's one for a tattoo parlor: “I was so happy with how it came out. It is really simple, just tracing my handwriting, but every day I am amazed at how authentic it looks!”

Sites like Yelp represent a larger cultural trend fostered by the Internet, which lets anyone anywhere say anything to everyone everywhere. In this respect, the Internet is a great leveler that sweeps away rank and privilege and lets professors and peons alike hold forth on history, medicine, or fast-food joints. Those who choose to can show the universe their picture; share their birthdays, hobbies, and preferences; and let the world read more about them.

The effects of this trend are still evolving, but they are likely to be profound and may have increasing relevance to physicians. Consumer Aware and Blue Cross Blue Shield of Minnesota have set up a Yelp-like site, www.thehealthcarescoop.com

“My daughter died of heart failure at the [XYZ] Heart Hospital. [She] had an aortic valve replacement. … She was 28 when she went in for her aftercare checkup with the surgeon, she died a day later in the hospital. The medical team assigned to her, as well as her surgeon, did not respond with any urgency even though there was an infection present, she was given no antibiotics. … Hindsight tells me that she would be alive today had the proper care been taken at the time she came in for her aftercare checkup.”

Here's another: “My wife was scheduled for her first colonoscopy so she was naturally nervous. The staff at the [ABC] Clinic made her feel very comfortable. They were very attentive during the recovery time and even followed up with a 'check-in' phone call after the procedure to see how she was doing. The [ABC] Clinic is great.”

Is XYZ Heart Hospital incompetent? Is ABC Clinic superb? “Reviews” like these give us no real idea. Those who write them are, of course, entitled to their opinions, and the nature of such opinions give us insight into the way real people—our patients—talk about us to their friends and family and judge how we've done.

But should society rate us on the basis of reviews of this kind? Will this become yet another flawed criterion that health insurers will use to implement pay for performance?

Maybe we should call our leaders and professional societies and do some yelping ourselves.

“I found you on Yelp,” said Erica. “You had the second most reviews.”

“Saw Dr. Rockoff and was extremely disappointed. … The first time I visited, I was put on a very aggressive treatment plan which ended up not helping my skin problems. When I went back for a follow up, he recommended the same products insisting that I had not tried them yet … when he himself had prescribed them to me 2 months earlier!” Kristen Z.

I looked at Kristen's chart. The “very aggressive” plan was benzoyl peroxide, clindamycin gel, and minocycline. She had used doxycycline, tretinoin, and adapalene for years. At her return visit, I added tazarotene. A month later, she called for refills.

Pretty sharp and accurate review, yes?

Other notices were more favorable. Here's one:

“I go to the Rockoff Center for all my facial needs. This is a dermatologist office, so it is much better than going to a spa.”

So, I guess all that medical school was worth it after all.

But Yelp doesn't limit itself to dermatologists, or even to physicians. You can also read reviews of restaurants, shopping, nightlife, and beauty and spas. In the last category, here's one for a tattoo parlor: “I was so happy with how it came out. It is really simple, just tracing my handwriting, but every day I am amazed at how authentic it looks!”

Sites like Yelp represent a larger cultural trend fostered by the Internet, which lets anyone anywhere say anything to everyone everywhere. In this respect, the Internet is a great leveler that sweeps away rank and privilege and lets professors and peons alike hold forth on history, medicine, or fast-food joints. Those who choose to can show the universe their picture; share their birthdays, hobbies, and preferences; and let the world read more about them.

The effects of this trend are still evolving, but they are likely to be profound and may have increasing relevance to physicians. Consumer Aware and Blue Cross Blue Shield of Minnesota have set up a Yelp-like site, www.thehealthcarescoop.com

“My daughter died of heart failure at the [XYZ] Heart Hospital. [She] had an aortic valve replacement. … She was 28 when she went in for her aftercare checkup with the surgeon, she died a day later in the hospital. The medical team assigned to her, as well as her surgeon, did not respond with any urgency even though there was an infection present, she was given no antibiotics. … Hindsight tells me that she would be alive today had the proper care been taken at the time she came in for her aftercare checkup.”

Here's another: “My wife was scheduled for her first colonoscopy so she was naturally nervous. The staff at the [ABC] Clinic made her feel very comfortable. They were very attentive during the recovery time and even followed up with a 'check-in' phone call after the procedure to see how she was doing. The [ABC] Clinic is great.”

Is XYZ Heart Hospital incompetent? Is ABC Clinic superb? “Reviews” like these give us no real idea. Those who write them are, of course, entitled to their opinions, and the nature of such opinions give us insight into the way real people—our patients—talk about us to their friends and family and judge how we've done.

But should society rate us on the basis of reviews of this kind? Will this become yet another flawed criterion that health insurers will use to implement pay for performance?

Maybe we should call our leaders and professional societies and do some yelping ourselves.

On Wednesday, little Esmeralda's eczema took a turn for the worse. "It's infected," I told her mother, "so I'm prescribing this antibiotic syrup and topical cream. Here is my private extension. I need you to call me first thing Friday morning so I'll know how she's doing before the long weekend."

No message was waiting Friday, so I called at 9 a.m. and left one myself. I left another at noon. As I was preparing to leave at 2 p.m., Esmeralda's mother called, not to tell me that her daughter was improving, which she was, but to ask me to fax a report to Esmeralda's day care providers. I offered to call instead. "No," she said, "I need you to fax them what you recommended."

That same Wednesday, I got a call from a pulmonologist. A mutual patient, Fishbane, had come down with tuberculosis but was itching like crazy and refusing to take his medications. He needed to see me at once, but I was in my other office and he wouldn't come there. Could I see him Thursday? Sure. Arrangements were made, with thanks for my being so helpful. Fishbane never showed.

All this is familiar, of course: Patients follow through when it suits their needs.

"Hi, Henry. It's been 5 years. Are you back because you had that squamous cell, and I asked you to come annually?"

"Oh no, Doc. I have this new spot I'm worried about."

Nonhermits have many kinds of relationships. These relationships involve needs that each party satisfies to some extent. In the doctor-patient relationship, patients need us to diagnose correctly, prescribe properly, and behave with courtesy. We need them to show up, call back, and either cooperate with treatment or at least let us know why they can't.

Relationships flourish when people make allowances, but they founder when needs, duties, and shortcomings are aggressively spelled out.

"I've been waiting an hour," hissed Spencer. "I'm a professional like you, and I too have other appointments. It's clear that you care only about your own needs, not mine."

Maybe Spencer is just having a bad day, but suppose he's always like that. Imagine being married to him. His complaint is not without merit, but I have needs too. Spencer wants to get on with his day. I want to stay busy even when some patients don't show, others come late, and still others must be fit in right away (or, like Fishbane, claim they do).

Most of us know we'll get only some of what we need and decide to muddle through. Patients expect to wait a while. Doctors know that many patients won't remember which treatments didn't work. Some people, though, aren't satisfied with muddling and demand precision: yes or no, right or wrong, exactly how many minutes' wait is too many. That's how lawyers and bureaucrats think—an approach useful in its place but toxic to ordinary relationships, which are rife with fuzziness and ambiguity. Think of the difference between the arrangements a husband and wife make to pick up their kids versus those dictated by a divorce court.

"Thanks for taking off my wart, doctor," says Sue. "Would it be okay if I asked you one more question?" Well, sure, especially since you're asking so nicely.

But what about Phyllis, who has nine separate issues to discuss with magisterial deliberation and a sense of serene entitlement, and who catches you at the door trying to escape with, "And oh yes, doctor, my hair is falling out"?

How many questions does Phyllis have a right to ask? One? Three? Six from column A and two from column B? She needs to have her concerns addressed, but I have needs too. I need to get the heck out and see another patient. Sue is very considerate, but now and then the office serves up a Phyllis, just as life brings us bores who won't shut up or guests who won't leave.

Most people are considerate; others are endlessly needy. One way or another, we negotiate needs all day long. Considering how many people we deal with every day, it's a wonder how well things usually go. Sometimes a Phyllis or two shows up and throws things off. Then we can go home and crack open a beer. Whack a golf ball. Write a column.

On Wednesday, little Esmeralda's eczema took a turn for the worse. "It's infected," I told her mother, "so I'm prescribing this antibiotic syrup and topical cream. Here is my private extension. I need you to call me first thing Friday morning so I'll know how she's doing before the long weekend."

No message was waiting Friday, so I called at 9 a.m. and left one myself. I left another at noon. As I was preparing to leave at 2 p.m., Esmeralda's mother called, not to tell me that her daughter was improving, which she was, but to ask me to fax a report to Esmeralda's day care providers. I offered to call instead. "No," she said, "I need you to fax them what you recommended."

That same Wednesday, I got a call from a pulmonologist. A mutual patient, Fishbane, had come down with tuberculosis but was itching like crazy and refusing to take his medications. He needed to see me at once, but I was in my other office and he wouldn't come there. Could I see him Thursday? Sure. Arrangements were made, with thanks for my being so helpful. Fishbane never showed.

All this is familiar, of course: Patients follow through when it suits their needs.

"Hi, Henry. It's been 5 years. Are you back because you had that squamous cell, and I asked you to come annually?"

"Oh no, Doc. I have this new spot I'm worried about."

Nonhermits have many kinds of relationships. These relationships involve needs that each party satisfies to some extent. In the doctor-patient relationship, patients need us to diagnose correctly, prescribe properly, and behave with courtesy. We need them to show up, call back, and either cooperate with treatment or at least let us know why they can't.

Relationships flourish when people make allowances, but they founder when needs, duties, and shortcomings are aggressively spelled out.

"I've been waiting an hour," hissed Spencer. "I'm a professional like you, and I too have other appointments. It's clear that you care only about your own needs, not mine."

Maybe Spencer is just having a bad day, but suppose he's always like that. Imagine being married to him. His complaint is not without merit, but I have needs too. Spencer wants to get on with his day. I want to stay busy even when some patients don't show, others come late, and still others must be fit in right away (or, like Fishbane, claim they do).

Most of us know we'll get only some of what we need and decide to muddle through. Patients expect to wait a while. Doctors know that many patients won't remember which treatments didn't work. Some people, though, aren't satisfied with muddling and demand precision: yes or no, right or wrong, exactly how many minutes' wait is too many. That's how lawyers and bureaucrats think—an approach useful in its place but toxic to ordinary relationships, which are rife with fuzziness and ambiguity. Think of the difference between the arrangements a husband and wife make to pick up their kids versus those dictated by a divorce court.

"Thanks for taking off my wart, doctor," says Sue. "Would it be okay if I asked you one more question?" Well, sure, especially since you're asking so nicely.

But what about Phyllis, who has nine separate issues to discuss with magisterial deliberation and a sense of serene entitlement, and who catches you at the door trying to escape with, "And oh yes, doctor, my hair is falling out"?

How many questions does Phyllis have a right to ask? One? Three? Six from column A and two from column B? She needs to have her concerns addressed, but I have needs too. I need to get the heck out and see another patient. Sue is very considerate, but now and then the office serves up a Phyllis, just as life brings us bores who won't shut up or guests who won't leave.

Most people are considerate; others are endlessly needy. One way or another, we negotiate needs all day long. Considering how many people we deal with every day, it's a wonder how well things usually go. Sometimes a Phyllis or two shows up and throws things off. Then we can go home and crack open a beer. Whack a golf ball. Write a column.

On Wednesday, little Esmeralda's eczema took a turn for the worse. "It's infected," I told her mother, "so I'm prescribing this antibiotic syrup and topical cream. Here is my private extension. I need you to call me first thing Friday morning so I'll know how she's doing before the long weekend."

No message was waiting Friday, so I called at 9 a.m. and left one myself. I left another at noon. As I was preparing to leave at 2 p.m., Esmeralda's mother called, not to tell me that her daughter was improving, which she was, but to ask me to fax a report to Esmeralda's day care providers. I offered to call instead. "No," she said, "I need you to fax them what you recommended."

That same Wednesday, I got a call from a pulmonologist. A mutual patient, Fishbane, had come down with tuberculosis but was itching like crazy and refusing to take his medications. He needed to see me at once, but I was in my other office and he wouldn't come there. Could I see him Thursday? Sure. Arrangements were made, with thanks for my being so helpful. Fishbane never showed.

All this is familiar, of course: Patients follow through when it suits their needs.

"Hi, Henry. It's been 5 years. Are you back because you had that squamous cell, and I asked you to come annually?"

"Oh no, Doc. I have this new spot I'm worried about."

Nonhermits have many kinds of relationships. These relationships involve needs that each party satisfies to some extent. In the doctor-patient relationship, patients need us to diagnose correctly, prescribe properly, and behave with courtesy. We need them to show up, call back, and either cooperate with treatment or at least let us know why they can't.

Relationships flourish when people make allowances, but they founder when needs, duties, and shortcomings are aggressively spelled out.

"I've been waiting an hour," hissed Spencer. "I'm a professional like you, and I too have other appointments. It's clear that you care only about your own needs, not mine."

Maybe Spencer is just having a bad day, but suppose he's always like that. Imagine being married to him. His complaint is not without merit, but I have needs too. Spencer wants to get on with his day. I want to stay busy even when some patients don't show, others come late, and still others must be fit in right away (or, like Fishbane, claim they do).

Most of us know we'll get only some of what we need and decide to muddle through. Patients expect to wait a while. Doctors know that many patients won't remember which treatments didn't work. Some people, though, aren't satisfied with muddling and demand precision: yes or no, right or wrong, exactly how many minutes' wait is too many. That's how lawyers and bureaucrats think—an approach useful in its place but toxic to ordinary relationships, which are rife with fuzziness and ambiguity. Think of the difference between the arrangements a husband and wife make to pick up their kids versus those dictated by a divorce court.

"Thanks for taking off my wart, doctor," says Sue. "Would it be okay if I asked you one more question?" Well, sure, especially since you're asking so nicely.

But what about Phyllis, who has nine separate issues to discuss with magisterial deliberation and a sense of serene entitlement, and who catches you at the door trying to escape with, "And oh yes, doctor, my hair is falling out"?

How many questions does Phyllis have a right to ask? One? Three? Six from column A and two from column B? She needs to have her concerns addressed, but I have needs too. I need to get the heck out and see another patient. Sue is very considerate, but now and then the office serves up a Phyllis, just as life brings us bores who won't shut up or guests who won't leave.

Most people are considerate; others are endlessly needy. One way or another, we negotiate needs all day long. Considering how many people we deal with every day, it's a wonder how well things usually go. Sometimes a Phyllis or two shows up and throws things off. Then we can go home and crack open a beer. Whack a golf ball. Write a column.

When I started my practice, patients found me through the Yellow Pages. “I recognized your address,” they said, or “You were convenient.” It seemed a little impersonal, but what could I expect? I was new.

Later, patients found me on HMO lists. Their physicians referred them because I was the only dermatologist on the rosters at the time, my older colleagues having refused to join. I dutifully sent referral letters to physicians I didn't know: “Dear Doctor: Thank you for referring Jane. I am treating her acne with such-and-such.” Perhaps they read them.

As my fame and reputation grew, I began getting referrals from doctors' receptionists. “They gave me a list,” patients would say.” 'Here are the three dermatologists we use.' The lady at the front desk suggested you.” An article I once wrote for a medical magazine was titled, “My Doctor's Receptionist's Hairdresser Sent Me Over.”

I understood all this. Even before our field became synonymous in the public mind with Botox and cosmetic fluff, nondermatologists thought of skin diseases as something exotic and superficial (“It's one of those skin things. Go see a skin guy.”), if not alien and frightening (“Lordy, it's one of those skin things! Go see a skin guy!”).

I could be wrong, but I can't imagine similar referrals to other specialties. (“Your ticker is tocking. Go see a heart guy.”) In any case, even when patients have come from other physicians, I have rarely felt a sense of the real collegiality I imagine takes place in hospital corridors and cafeterias. Once in a great while over the years, I've gotten an urgent call from a doctor in my own building eager to send down a patient with a dramatic rash, and I've even gone upstairs myself while the patient was still with the internist or surgeon. Such occasions have been uniquely satisfying, though rare enough that I can actually remember them.

Now that I've been around for a long time, many of the doctors who used to refer patients to me, one way or another, have retired, slowed down, or gone concierge. Also, more people have PPOs that don't require physician referral. As a result, when I ask, “Who referred you to me?” I'm apt to hear, “I looked you up online on my insurer's Web site, and I recognized your address. You were convenient.” Higher tech, but familiar.

Sometimes people are referred by other people. “I got your name from a friend,” they'll say.

“Neat. Which friend?”

“Uhhh … actually, I think it was my mother-in-law's friend.”

Then of course there's Google. “I did an Internet search,” a new patient says.

“No kidding,” I reply. “What did you search for?”

“Dermatologists in Brookline.”

Makes you feel warm and fuzzy all over, doesn't it?

One patient was more flattering. “I Googled 'Top Dermatologists, Brookline.'”

Wow, I thought. I've been optimized.

I Googled that myself, and what came up first was an Internet Yellow Pages site with a list called “Featured Advertisers: Dermatology” on top, the first of which was an animal hospital, with an offer to “get coupon for pet's first visit!” Next to that was a listing for a (human) dermatologist in a town 20 miles north. Scrolling down past more advertisers and a long paragraph of skin-related keywords, I found actual dermatologists in Brookline. I came in second, with an incorrect address.

Just for fun, I Googled “Bottom Dermatologist Brookline.” The top listing for that was an answer on a medical Web site that I wrote in 2005 to a worried questioner who had pimples on his bottom. Bottom's up!

Not long ago, I saw a patient who identified herself as a “health writer for the Wall Street Journal.” After I examined her, she asked me for the name of an internist. “I need someone affiliated with a major teaching hospital,” she explained. “In case I get sick, I need access to the most advanced medical care. I'm a sophisticated medical consumer,” she added. “After all, I'm a health writer for the Wall Street Journal.”

I gave her the names of two doctors. “By the way,” I asked her, “how did you find me?”

“The mailman,” she said. “I met him while I was walking by your building, and he told me he hears you're good.”

Well, I am the only dermatologist in the building.

When I started my practice, patients found me through the Yellow Pages. “I recognized your address,” they said, or “You were convenient.” It seemed a little impersonal, but what could I expect? I was new.

Later, patients found me on HMO lists. Their physicians referred them because I was the only dermatologist on the rosters at the time, my older colleagues having refused to join. I dutifully sent referral letters to physicians I didn't know: “Dear Doctor: Thank you for referring Jane. I am treating her acne with such-and-such.” Perhaps they read them.

As my fame and reputation grew, I began getting referrals from doctors' receptionists. “They gave me a list,” patients would say.” 'Here are the three dermatologists we use.' The lady at the front desk suggested you.” An article I once wrote for a medical magazine was titled, “My Doctor's Receptionist's Hairdresser Sent Me Over.”

I understood all this. Even before our field became synonymous in the public mind with Botox and cosmetic fluff, nondermatologists thought of skin diseases as something exotic and superficial (“It's one of those skin things. Go see a skin guy.”), if not alien and frightening (“Lordy, it's one of those skin things! Go see a skin guy!”).

I could be wrong, but I can't imagine similar referrals to other specialties. (“Your ticker is tocking. Go see a heart guy.”) In any case, even when patients have come from other physicians, I have rarely felt a sense of the real collegiality I imagine takes place in hospital corridors and cafeterias. Once in a great while over the years, I've gotten an urgent call from a doctor in my own building eager to send down a patient with a dramatic rash, and I've even gone upstairs myself while the patient was still with the internist or surgeon. Such occasions have been uniquely satisfying, though rare enough that I can actually remember them.

Now that I've been around for a long time, many of the doctors who used to refer patients to me, one way or another, have retired, slowed down, or gone concierge. Also, more people have PPOs that don't require physician referral. As a result, when I ask, “Who referred you to me?” I'm apt to hear, “I looked you up online on my insurer's Web site, and I recognized your address. You were convenient.” Higher tech, but familiar.

Sometimes people are referred by other people. “I got your name from a friend,” they'll say.

“Neat. Which friend?”

“Uhhh … actually, I think it was my mother-in-law's friend.”

Then of course there's Google. “I did an Internet search,” a new patient says.

“No kidding,” I reply. “What did you search for?”

“Dermatologists in Brookline.”

Makes you feel warm and fuzzy all over, doesn't it?

One patient was more flattering. “I Googled 'Top Dermatologists, Brookline.'”

Wow, I thought. I've been optimized.

I Googled that myself, and what came up first was an Internet Yellow Pages site with a list called “Featured Advertisers: Dermatology” on top, the first of which was an animal hospital, with an offer to “get coupon for pet's first visit!” Next to that was a listing for a (human) dermatologist in a town 20 miles north. Scrolling down past more advertisers and a long paragraph of skin-related keywords, I found actual dermatologists in Brookline. I came in second, with an incorrect address.

Just for fun, I Googled “Bottom Dermatologist Brookline.” The top listing for that was an answer on a medical Web site that I wrote in 2005 to a worried questioner who had pimples on his bottom. Bottom's up!

Not long ago, I saw a patient who identified herself as a “health writer for the Wall Street Journal.” After I examined her, she asked me for the name of an internist. “I need someone affiliated with a major teaching hospital,” she explained. “In case I get sick, I need access to the most advanced medical care. I'm a sophisticated medical consumer,” she added. “After all, I'm a health writer for the Wall Street Journal.”

I gave her the names of two doctors. “By the way,” I asked her, “how did you find me?”

“The mailman,” she said. “I met him while I was walking by your building, and he told me he hears you're good.”

Well, I am the only dermatologist in the building.

When I started my practice, patients found me through the Yellow Pages. “I recognized your address,” they said, or “You were convenient.” It seemed a little impersonal, but what could I expect? I was new.

Later, patients found me on HMO lists. Their physicians referred them because I was the only dermatologist on the rosters at the time, my older colleagues having refused to join. I dutifully sent referral letters to physicians I didn't know: “Dear Doctor: Thank you for referring Jane. I am treating her acne with such-and-such.” Perhaps they read them.

As my fame and reputation grew, I began getting referrals from doctors' receptionists. “They gave me a list,” patients would say.” 'Here are the three dermatologists we use.' The lady at the front desk suggested you.” An article I once wrote for a medical magazine was titled, “My Doctor's Receptionist's Hairdresser Sent Me Over.”

I understood all this. Even before our field became synonymous in the public mind with Botox and cosmetic fluff, nondermatologists thought of skin diseases as something exotic and superficial (“It's one of those skin things. Go see a skin guy.”), if not alien and frightening (“Lordy, it's one of those skin things! Go see a skin guy!”).

I could be wrong, but I can't imagine similar referrals to other specialties. (“Your ticker is tocking. Go see a heart guy.”) In any case, even when patients have come from other physicians, I have rarely felt a sense of the real collegiality I imagine takes place in hospital corridors and cafeterias. Once in a great while over the years, I've gotten an urgent call from a doctor in my own building eager to send down a patient with a dramatic rash, and I've even gone upstairs myself while the patient was still with the internist or surgeon. Such occasions have been uniquely satisfying, though rare enough that I can actually remember them.

Now that I've been around for a long time, many of the doctors who used to refer patients to me, one way or another, have retired, slowed down, or gone concierge. Also, more people have PPOs that don't require physician referral. As a result, when I ask, “Who referred you to me?” I'm apt to hear, “I looked you up online on my insurer's Web site, and I recognized your address. You were convenient.” Higher tech, but familiar.

Sometimes people are referred by other people. “I got your name from a friend,” they'll say.

“Neat. Which friend?”

“Uhhh … actually, I think it was my mother-in-law's friend.”

Then of course there's Google. “I did an Internet search,” a new patient says.

“No kidding,” I reply. “What did you search for?”

“Dermatologists in Brookline.”

Makes you feel warm and fuzzy all over, doesn't it?

One patient was more flattering. “I Googled 'Top Dermatologists, Brookline.'”

Wow, I thought. I've been optimized.

I Googled that myself, and what came up first was an Internet Yellow Pages site with a list called “Featured Advertisers: Dermatology” on top, the first of which was an animal hospital, with an offer to “get coupon for pet's first visit!” Next to that was a listing for a (human) dermatologist in a town 20 miles north. Scrolling down past more advertisers and a long paragraph of skin-related keywords, I found actual dermatologists in Brookline. I came in second, with an incorrect address.

Just for fun, I Googled “Bottom Dermatologist Brookline.” The top listing for that was an answer on a medical Web site that I wrote in 2005 to a worried questioner who had pimples on his bottom. Bottom's up!

Not long ago, I saw a patient who identified herself as a “health writer for the Wall Street Journal.” After I examined her, she asked me for the name of an internist. “I need someone affiliated with a major teaching hospital,” she explained. “In case I get sick, I need access to the most advanced medical care. I'm a sophisticated medical consumer,” she added. “After all, I'm a health writer for the Wall Street Journal.”

I gave her the names of two doctors. “By the way,” I asked her, “how did you find me?”

“The mailman,” she said. “I met him while I was walking by your building, and he told me he hears you're good.”

Well, I am the only dermatologist in the building.

“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”

Silence.

“Has the clindamycin lotion in the morning helped with dryness?”

Silence.

“How often do you put the creams on?”

Silence.

It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.

“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”

Silence.

“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”

Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.

The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?

Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.

These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:

P Never give an adolescent male more than two things to do.

P Ask for twice a day, hope for once.

P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.

When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”

In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.

Well, I can dream, can't I?

Those who analyze nonadherence point out factors that contribute to it or might help counter it.

The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.

Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?

I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?

Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.

“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”

Silence.

“Has the clindamycin lotion in the morning helped with dryness?”

Silence.

“How often do you put the creams on?”

Silence.

It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.

“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”

Silence.

“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”

Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.

The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?

Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.

These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:

P Never give an adolescent male more than two things to do.

P Ask for twice a day, hope for once.

P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.

When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”

In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.

Well, I can dream, can't I?

Those who analyze nonadherence point out factors that contribute to it or might help counter it.

The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.

Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?

I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?

Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.

“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”

Silence.

“Has the clindamycin lotion in the morning helped with dryness?”

Silence.

“How often do you put the creams on?”

Silence.

It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.

“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”

Silence.

“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”

Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.

The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?

Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.

These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:

P Never give an adolescent male more than two things to do.

P Ask for twice a day, hope for once.

P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.

When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”

In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.

Well, I can dream, can't I?

Those who analyze nonadherence point out factors that contribute to it or might help counter it.

The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.

Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?

I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?

Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession—the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy, oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession—the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy, oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession—the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy, oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

Nondermatologists like to mock, "Hey, we know what you guys do: If it's wet, dry it, and if it's dry, wet it."

Most of the students who follow me around are headed for primary care. When I meet a new one, I'm tempted to say, "The goal of this elective is to make sure that, by the time you leave, you won't say, 'If it's eczema, I'll treat it as a fungus, and if it's a fungus, I'll treat it with a steroid.'"

That would be snide and condescending, though, so I stifle the impulse. But then comes a new student, Darlene, and a day like last Thursday. …

Case 1

"Doc, I have this rash between my butt cheeks, and the cream I'm using doesn't help at all."

"Which cream is that?"

"Clotrimazole."

"See the pinkness spanning the cleft?" I show Darlene. "That's inverse psoriasis, so clotrimazole won't work. He needs a steroid."

Case 2

"It's been a week, Fred. How are you?"

"My butt feels much better, Doc. The itch was maddening."

His gluteal cleft looks all clear. A couple of weeks of nystatin-triamcinolone had left him with a nice rim of satellite pustules and a lot of itch. Econazole did the trick.

"He had a yeast infection," I say. "The triamcinolone trumped the nystatin. A straight antiyeast cream is what he needed."

"Isn't that the opposite of the other patient?" Darlene asks.

The kids are so smart these days.

Case 3

"How long has Vince had this scaling on his soles?"

"He's 10, so I guess it's about 6 years."

"And what has his pediatrician recommended?"

"An antifungal cream. It sort of works. After 2 weeks of using it, the scaling is a little better."

"Let's try a different approach. Foot rashes on prepubertal kids are usually eczematous rather than fungal," I explain.

"Why didn't the pediatrician change the prescription?" Darlene asks.

"Probably because the patient didn't complain. The fungus cream is a cream, after all, so it smoothed things down a bit."

"But for 6 years?"

Case 4

Ricardo has a patch of psoriasis peeking out from his right frontal scalp. Nice pink, micaceous scale. Clearly defined outline. Treatment hasn't been working.

"What did you use?"

"My doctor gave me a cream and some pills. I wrote it down—griseofulvin. I took it for a month, but it didn't help."

"Tinea affects the scalp mostly in kids," I tell Darlene, "and Ricardo is 23. Also, tinea causes hair loss, which he doesn't have."

"If it's inflammatory, treat it as a fungus," she says with a sly smile, "and if it's a fungus …"

"You said it," I tell her, "but I thought it."

The Internet Post

Thursday was unusual, but such stories are not. Here's a typical Internet post:

I saw a doctor a couple times because a small lesion appeared near my urethra last September. It's small and doesn't bother me much, but it weeps a clear fluid. It also came along with dry skin/redness on my scrotum, which bothers me occasionally. The doctor told me it was nothing to worry about and it was just a fungus.

What fungus would that be, exactly?

Differentiating an inflammatory dermatosis from a fungus or yeast can be tricky: Scrapings are sometimes unreliable, cultures delayed and overgrown with contaminants.

I confess to my share of "whoops" moments when the sight of spreading, polycyclic lesions on the ankles or neck showed that a topical steroid might not have been such a good idea after all. When it comes to papulosquamous rashes, there are just two basic choices—fungus or not fungus—and two outcomes—better and not better. This isn't rocket science.

Yet, year in and year out, people troop in to show me nummular eczema that their doctors, some even older than I am, have been treating with endless applications of Lamisil (terbinafine) or clotrimazole. The monotony of such cases is relieved only by the occasional unfortunate with Candida or tinea who's never been taken off the triamcinolone or steroid-antifungal combination that's clearly making things worse.

There's a big push these days to rate (and pay) physicians based on their efficient use of evidence-based therapies with reliable outcomes. Here, I suggest, is a good place to start: Train doctors while they're still in school that, wet or dry, if it's a fungus, treat it as one, and if it isn't, don't.

Nondermatologists like to mock, "Hey, we know what you guys do: If it's wet, dry it, and if it's dry, wet it."

Most of the students who follow me around are headed for primary care. When I meet a new one, I'm tempted to say, "The goal of this elective is to make sure that, by the time you leave, you won't say, 'If it's eczema, I'll treat it as a fungus, and if it's a fungus, I'll treat it with a steroid.'"

That would be snide and condescending, though, so I stifle the impulse. But then comes a new student, Darlene, and a day like last Thursday. …

Case 1

"Doc, I have this rash between my butt cheeks, and the cream I'm using doesn't help at all."

"Which cream is that?"

"Clotrimazole."

"See the pinkness spanning the cleft?" I show Darlene. "That's inverse psoriasis, so clotrimazole won't work. He needs a steroid."

Case 2

"It's been a week, Fred. How are you?"

"My butt feels much better, Doc. The itch was maddening."

His gluteal cleft looks all clear. A couple of weeks of nystatin-triamcinolone had left him with a nice rim of satellite pustules and a lot of itch. Econazole did the trick.

"He had a yeast infection," I say. "The triamcinolone trumped the nystatin. A straight antiyeast cream is what he needed."

"Isn't that the opposite of the other patient?" Darlene asks.

The kids are so smart these days.

Case 3

"How long has Vince had this scaling on his soles?"

"He's 10, so I guess it's about 6 years."

"And what has his pediatrician recommended?"

"An antifungal cream. It sort of works. After 2 weeks of using it, the scaling is a little better."

"Let's try a different approach. Foot rashes on prepubertal kids are usually eczematous rather than fungal," I explain.

"Why didn't the pediatrician change the prescription?" Darlene asks.

"Probably because the patient didn't complain. The fungus cream is a cream, after all, so it smoothed things down a bit."

"But for 6 years?"

Case 4

Ricardo has a patch of psoriasis peeking out from his right frontal scalp. Nice pink, micaceous scale. Clearly defined outline. Treatment hasn't been working.

"What did you use?"

"My doctor gave me a cream and some pills. I wrote it down—griseofulvin. I took it for a month, but it didn't help."

"Tinea affects the scalp mostly in kids," I tell Darlene, "and Ricardo is 23. Also, tinea causes hair loss, which he doesn't have."

"If it's inflammatory, treat it as a fungus," she says with a sly smile, "and if it's a fungus …"

"You said it," I tell her, "but I thought it."

The Internet Post

Thursday was unusual, but such stories are not. Here's a typical Internet post:

I saw a doctor a couple times because a small lesion appeared near my urethra last September. It's small and doesn't bother me much, but it weeps a clear fluid. It also came along with dry skin/redness on my scrotum, which bothers me occasionally. The doctor told me it was nothing to worry about and it was just a fungus.

What fungus would that be, exactly?

Differentiating an inflammatory dermatosis from a fungus or yeast can be tricky: Scrapings are sometimes unreliable, cultures delayed and overgrown with contaminants.

I confess to my share of "whoops" moments when the sight of spreading, polycyclic lesions on the ankles or neck showed that a topical steroid might not have been such a good idea after all. When it comes to papulosquamous rashes, there are just two basic choices—fungus or not fungus—and two outcomes—better and not better. This isn't rocket science.

Yet, year in and year out, people troop in to show me nummular eczema that their doctors, some even older than I am, have been treating with endless applications of Lamisil (terbinafine) or clotrimazole. The monotony of such cases is relieved only by the occasional unfortunate with Candida or tinea who's never been taken off the triamcinolone or steroid-antifungal combination that's clearly making things worse.

There's a big push these days to rate (and pay) physicians based on their efficient use of evidence-based therapies with reliable outcomes. Here, I suggest, is a good place to start: Train doctors while they're still in school that, wet or dry, if it's a fungus, treat it as one, and if it isn't, don't.

Nondermatologists like to mock, "Hey, we know what you guys do: If it's wet, dry it, and if it's dry, wet it."

Most of the students who follow me around are headed for primary care. When I meet a new one, I'm tempted to say, "The goal of this elective is to make sure that, by the time you leave, you won't say, 'If it's eczema, I'll treat it as a fungus, and if it's a fungus, I'll treat it with a steroid.'"

That would be snide and condescending, though, so I stifle the impulse. But then comes a new student, Darlene, and a day like last Thursday. …

Case 1

"Doc, I have this rash between my butt cheeks, and the cream I'm using doesn't help at all."

"Which cream is that?"

"Clotrimazole."

"See the pinkness spanning the cleft?" I show Darlene. "That's inverse psoriasis, so clotrimazole won't work. He needs a steroid."

Case 2

"It's been a week, Fred. How are you?"

"My butt feels much better, Doc. The itch was maddening."

His gluteal cleft looks all clear. A couple of weeks of nystatin-triamcinolone had left him with a nice rim of satellite pustules and a lot of itch. Econazole did the trick.

"He had a yeast infection," I say. "The triamcinolone trumped the nystatin. A straight antiyeast cream is what he needed."

"Isn't that the opposite of the other patient?" Darlene asks.

The kids are so smart these days.

Case 3

"How long has Vince had this scaling on his soles?"

"He's 10, so I guess it's about 6 years."

"And what has his pediatrician recommended?"

"An antifungal cream. It sort of works. After 2 weeks of using it, the scaling is a little better."

"Let's try a different approach. Foot rashes on prepubertal kids are usually eczematous rather than fungal," I explain.

"Why didn't the pediatrician change the prescription?" Darlene asks.

"Probably because the patient didn't complain. The fungus cream is a cream, after all, so it smoothed things down a bit."

"But for 6 years?"

Case 4

Ricardo has a patch of psoriasis peeking out from his right frontal scalp. Nice pink, micaceous scale. Clearly defined outline. Treatment hasn't been working.

"What did you use?"

"My doctor gave me a cream and some pills. I wrote it down—griseofulvin. I took it for a month, but it didn't help."

"Tinea affects the scalp mostly in kids," I tell Darlene, "and Ricardo is 23. Also, tinea causes hair loss, which he doesn't have."

"If it's inflammatory, treat it as a fungus," she says with a sly smile, "and if it's a fungus …"

"You said it," I tell her, "but I thought it."

The Internet Post

Thursday was unusual, but such stories are not. Here's a typical Internet post:

I saw a doctor a couple times because a small lesion appeared near my urethra last September. It's small and doesn't bother me much, but it weeps a clear fluid. It also came along with dry skin/redness on my scrotum, which bothers me occasionally. The doctor told me it was nothing to worry about and it was just a fungus.

What fungus would that be, exactly?

Differentiating an inflammatory dermatosis from a fungus or yeast can be tricky: Scrapings are sometimes unreliable, cultures delayed and overgrown with contaminants.

I confess to my share of "whoops" moments when the sight of spreading, polycyclic lesions on the ankles or neck showed that a topical steroid might not have been such a good idea after all. When it comes to papulosquamous rashes, there are just two basic choices—fungus or not fungus—and two outcomes—better and not better. This isn't rocket science.

Yet, year in and year out, people troop in to show me nummular eczema that their doctors, some even older than I am, have been treating with endless applications of Lamisil (terbinafine) or clotrimazole. The monotony of such cases is relieved only by the occasional unfortunate with Candida or tinea who's never been taken off the triamcinolone or steroid-antifungal combination that's clearly making things worse.

There's a big push these days to rate (and pay) physicians based on their efficient use of evidence-based therapies with reliable outcomes. Here, I suggest, is a good place to start: Train doctors while they're still in school that, wet or dry, if it's a fungus, treat it as one, and if it isn't, don't.

The first boss I had after leaving my pediatric residency had trained at the Harriet Lane service at Johns Hopkins. One day he started reminiscing about how things had changed since his day. I had taken night call once every third night in my residency, and the residents at our UConn-affiliated program were currently on every fourth.

"At Hopkins they made a concession while I was there—they allowed us to get married. We were on every other night, but we couldn't leave the compound even on the off nights. That's why they called us interns—in case one of our own patients got sick."

"Sure," I remember thinking at the time, "the Days of the Giants." I resented his clear subtext: "You whippersnappers don't work like we did."

I was young, though, and not yet acquainted with the wisdom of great philosophers like Mel Brooks' 2000-year-old man ("We mock the thing we are to be") and Pogo ("We have met the enemy and he is us").

The Romans used to say that times change, and we change with them. What triggered my thinking of changing times has been the doings not just of young folks but of colleagues my age or older.

My medical neighborhood has been infected with "conciergitis": All at once, several established internists joined the boutique bandwagon, slashed their panels from a few thousand patients to a few hundred, and asked those who signed on to pay annual fees of $1,500-$4,000 over and above what insurance pays.

And what do the patients get for these fees? The promise of being able to reach their doctors promptly, be seen fast, and have phone calls returned.

Funny, I thought that's what doctors were supposed to do anyway. How old-fashioned of me.

Doctors are "boutiquing" both because they feel they need to and because they can. My own internist of 25 years, Doug, ferociously opposed concierge medicine when it first appeared around here a few years ago, yet he has recently signed on with a national boutique firm.

"My only other choice was to retire," he told me. "My junior associate Karen is only 34, but she's burned out after only 4 years. She's taken a job as a hospitalist so she can have a personal life. My partner quit primary care and took a job doing just GI. With all the paperwork and staffing costs, the practice wasn't financially viable if I ran it myself."

Times change in many ways. Besides new circumstances like the burdens of paperwork and government regulations, there are also shifting attitudes and expectations.

Slowly, imperceptibly, people decide they're no longer willing to do what used to be taken for granted. They want personal lives. They find out that Peter, Paul, and Meg aren't putting up with things everyone used to accept, so the scales fall from their eyes and they don't see why they should either.

Times change whether we want them to or not, but changing with them gets harder as we age and our adaptive arteries harden.

Starting out, I built my practice on HMO referrals because many older colleagues decided that HMOs were just a fad and they weren't going along with the referral thing. Eventually, most came around because they had to. Those who didn't gave up and quit.

No need to enumerate all the changes since then: E/M codes, OSHA, CLIA, EMRs, etc. And the pace of change isn't slowing down.

As times change, one thing seems to stay the same: Older folks think that youngsters don't know what real work means, and the younger generation does not want to hear it.

When I took over the remains of a practice in 1981, the retiring gentleman showed me around his office, a converted garage, and said, "You newcomers can't get along without things we never needed. You insist on secretaries." I was too polite to respond, but I remember what I thought.

Like the man said, "We mock the thing we are to be."

Now, at the other end of my career, I face the prospect of hiring younger associates who will expect to earn guaranteed top dollar the first year out of training and, of course, to work no more than 4 days a week.

I could tell them my personal saga—the first office in the back room of a brownstone, the many part-time jobs while waiting for the phone to ring, and so forth—but nobody wants to hear that. Times change. This is now.

Either you have the flexibility to change with the times or you decide it's not worth the effort anymore. I'm trying to be flexible. Doug may have concierged off into the sunset, but I found another doctor who calls me back, even without a membership fee. He only has office hours on 4 days, but, hey, nobody's perfect.

The first boss I had after leaving my pediatric residency had trained at the Harriet Lane service at Johns Hopkins. One day he started reminiscing about how things had changed since his day. I had taken night call once every third night in my residency, and the residents at our UConn-affiliated program were currently on every fourth.

"At Hopkins they made a concession while I was there—they allowed us to get married. We were on every other night, but we couldn't leave the compound even on the off nights. That's why they called us interns—in case one of our own patients got sick."

"Sure," I remember thinking at the time, "the Days of the Giants." I resented his clear subtext: "You whippersnappers don't work like we did."

I was young, though, and not yet acquainted with the wisdom of great philosophers like Mel Brooks' 2000-year-old man ("We mock the thing we are to be") and Pogo ("We have met the enemy and he is us").

The Romans used to say that times change, and we change with them. What triggered my thinking of changing times has been the doings not just of young folks but of colleagues my age or older.

My medical neighborhood has been infected with "conciergitis": All at once, several established internists joined the boutique bandwagon, slashed their panels from a few thousand patients to a few hundred, and asked those who signed on to pay annual fees of $1,500-$4,000 over and above what insurance pays.

And what do the patients get for these fees? The promise of being able to reach their doctors promptly, be seen fast, and have phone calls returned.

Funny, I thought that's what doctors were supposed to do anyway. How old-fashioned of me.

Doctors are "boutiquing" both because they feel they need to and because they can. My own internist of 25 years, Doug, ferociously opposed concierge medicine when it first appeared around here a few years ago, yet he has recently signed on with a national boutique firm.

"My only other choice was to retire," he told me. "My junior associate Karen is only 34, but she's burned out after only 4 years. She's taken a job as a hospitalist so she can have a personal life. My partner quit primary care and took a job doing just GI. With all the paperwork and staffing costs, the practice wasn't financially viable if I ran it myself."

Times change in many ways. Besides new circumstances like the burdens of paperwork and government regulations, there are also shifting attitudes and expectations.

Slowly, imperceptibly, people decide they're no longer willing to do what used to be taken for granted. They want personal lives. They find out that Peter, Paul, and Meg aren't putting up with things everyone used to accept, so the scales fall from their eyes and they don't see why they should either.

Times change whether we want them to or not, but changing with them gets harder as we age and our adaptive arteries harden.

Starting out, I built my practice on HMO referrals because many older colleagues decided that HMOs were just a fad and they weren't going along with the referral thing. Eventually, most came around because they had to. Those who didn't gave up and quit.

No need to enumerate all the changes since then: E/M codes, OSHA, CLIA, EMRs, etc. And the pace of change isn't slowing down.

As times change, one thing seems to stay the same: Older folks think that youngsters don't know what real work means, and the younger generation does not want to hear it.

When I took over the remains of a practice in 1981, the retiring gentleman showed me around his office, a converted garage, and said, "You newcomers can't get along without things we never needed. You insist on secretaries." I was too polite to respond, but I remember what I thought.

Like the man said, "We mock the thing we are to be."

Now, at the other end of my career, I face the prospect of hiring younger associates who will expect to earn guaranteed top dollar the first year out of training and, of course, to work no more than 4 days a week.

I could tell them my personal saga—the first office in the back room of a brownstone, the many part-time jobs while waiting for the phone to ring, and so forth—but nobody wants to hear that. Times change. This is now.

Either you have the flexibility to change with the times or you decide it's not worth the effort anymore. I'm trying to be flexible. Doug may have concierged off into the sunset, but I found another doctor who calls me back, even without a membership fee. He only has office hours on 4 days, but, hey, nobody's perfect.

The first boss I had after leaving my pediatric residency had trained at the Harriet Lane service at Johns Hopkins. One day he started reminiscing about how things had changed since his day. I had taken night call once every third night in my residency, and the residents at our UConn-affiliated program were currently on every fourth.

"At Hopkins they made a concession while I was there—they allowed us to get married. We were on every other night, but we couldn't leave the compound even on the off nights. That's why they called us interns—in case one of our own patients got sick."

"Sure," I remember thinking at the time, "the Days of the Giants." I resented his clear subtext: "You whippersnappers don't work like we did."

I was young, though, and not yet acquainted with the wisdom of great philosophers like Mel Brooks' 2000-year-old man ("We mock the thing we are to be") and Pogo ("We have met the enemy and he is us").

The Romans used to say that times change, and we change with them. What triggered my thinking of changing times has been the doings not just of young folks but of colleagues my age or older.

My medical neighborhood has been infected with "conciergitis": All at once, several established internists joined the boutique bandwagon, slashed their panels from a few thousand patients to a few hundred, and asked those who signed on to pay annual fees of $1,500-$4,000 over and above what insurance pays.

And what do the patients get for these fees? The promise of being able to reach their doctors promptly, be seen fast, and have phone calls returned.

Funny, I thought that's what doctors were supposed to do anyway. How old-fashioned of me.

Doctors are "boutiquing" both because they feel they need to and because they can. My own internist of 25 years, Doug, ferociously opposed concierge medicine when it first appeared around here a few years ago, yet he has recently signed on with a national boutique firm.

"My only other choice was to retire," he told me. "My junior associate Karen is only 34, but she's burned out after only 4 years. She's taken a job as a hospitalist so she can have a personal life. My partner quit primary care and took a job doing just GI. With all the paperwork and staffing costs, the practice wasn't financially viable if I ran it myself."

Times change in many ways. Besides new circumstances like the burdens of paperwork and government regulations, there are also shifting attitudes and expectations.

Slowly, imperceptibly, people decide they're no longer willing to do what used to be taken for granted. They want personal lives. They find out that Peter, Paul, and Meg aren't putting up with things everyone used to accept, so the scales fall from their eyes and they don't see why they should either.

Times change whether we want them to or not, but changing with them gets harder as we age and our adaptive arteries harden.

Starting out, I built my practice on HMO referrals because many older colleagues decided that HMOs were just a fad and they weren't going along with the referral thing. Eventually, most came around because they had to. Those who didn't gave up and quit.

No need to enumerate all the changes since then: E/M codes, OSHA, CLIA, EMRs, etc. And the pace of change isn't slowing down.

As times change, one thing seems to stay the same: Older folks think that youngsters don't know what real work means, and the younger generation does not want to hear it.

When I took over the remains of a practice in 1981, the retiring gentleman showed me around his office, a converted garage, and said, "You newcomers can't get along without things we never needed. You insist on secretaries." I was too polite to respond, but I remember what I thought.

Like the man said, "We mock the thing we are to be."

Now, at the other end of my career, I face the prospect of hiring younger associates who will expect to earn guaranteed top dollar the first year out of training and, of course, to work no more than 4 days a week.

I could tell them my personal saga—the first office in the back room of a brownstone, the many part-time jobs while waiting for the phone to ring, and so forth—but nobody wants to hear that. Times change. This is now.

Either you have the flexibility to change with the times or you decide it's not worth the effort anymore. I'm trying to be flexible. Doug may have concierged off into the sunset, but I found another doctor who calls me back, even without a membership fee. He only has office hours on 4 days, but, hey, nobody's perfect.

Chad sat on the exam table with an elegant black bag from Amphora, a local purveyor of high-end skin care products.

"I need a prescription for Protopic," he said.

"I'll put in for Prior Authorization," I replied. "But your insurance may not cover it."

So he asked for samples. Then he asked for a prescription for Propecia. Then he asked about Botox and Restylane.

People's attitudes toward spending money can be hard to figure. Take Eunice, for example, who came by later the same day for me to remove a lesion on her shin that biopsy had shown to be a basal cell carcinoma. She showed me another spot on her arm.

"Could be the same thing," I said.

"The last biopsy cost me $127 after insurance," she said. "Must you biopsy this one, too?"

I told her that I must.

While I curetted her leg and arm, Eunice reported on her recent trip. "The cruise was fabulous," she said. "We've tried different lines, but Royal Flushing is the best. There are thousands of passengers, but you always feel like you're getting personal service."

"Where did you go?" I asked.

"Athens, the Greek islands, Rome, Venice. You know what the best part was—Lido. It's a small island near Venice, away from the tourists, very quiet, really lovely."

And not covered by health insurance, presumably.

So it's okay to spend money on Propecia, Botox, and Lido, but not on Protopic or a biopsy.

But the paradox is only apparent, not real. In fact, people divide the world in two: things you're supposed to pay for and things somebody else is supposed to pay for. What matters is not the size of the expenditure, but the category. How things get classified is a matter for economic anthropologists to figure out. But get classified they do.

I mention Chad and Eunice not just because they're fresh in my mind but because they're middle class. The kind of paradoxical economic behavior I'm describing is more often blamed on "welfare queens." Money for frivolities while stinting the essentials.

Not that I exempt myself from such attitudes. I confess to irritation when Mrs. Will Medicaid Cover This? tells me about her recent jaunt to somewhere tropical. The phenomenon, however, is not limited to the poor, or to the bourgeoisie, petty or haute, which brings me to the wealthy.

Gilbert drops by twice a year. He tells me about his efforts to raise funds for his alma mater, a venerable and well-endowed southern institute of higher learning of which he is very proud.

"We set a goal of $1.3 billion for our capital campaign," he told me recently. "But we're already over a billion, so we've raised the goal to $1.7 billion."

I would have whistled if I knew how.

Gilbert went on to tell me about recruitment. "You might think we wouldn't do this with competitors," he said, "But we recruit with a consortium of other universities from our neck of the woods. It's more economical that way.

"Someone messed up when the recruiters went out to Denver last year and didn't book the hall we use every year. So they called one of the local private prep schools and asked about using an auditorium. They said sure, but it was going to cost $1,800. Can you imagine?

"So we said, hey, there's this consortium of well-known southern schools coming to your place. Our being there will do a lot for your prestige.

"They agreed that it would, and they'd be delighted to have us, but for $1,800."

"What did you do?" I asked him.

Gilbert smiled. "I have some contacts out there." He said. "One of them is a charter member of the Presbyopia Hunt Club. We used their facility, which worked out fine. It cost us $750."

Money for endowments? Check. Money for buildings and grounds? Check. Money for salaries? Nah, I know too many professors and postdoctorates to think that's the case.

Now if I were going on grandly about 10-figure sums, I would be, well, embarrassed to brag about how I saved a grand off somebody's standard fee which they didn't have the sense to discount for the honor of serving me. But that's just me.

The point is that no single class has a monopoly on inscrutable economic behavior. One should therefore be understanding and sympathetic to all. But the flesh is weak, and some people are, for me at least, a little harder to sympathize with.

Chad sat on the exam table with an elegant black bag from Amphora, a local purveyor of high-end skin care products.

"I need a prescription for Protopic," he said.

"I'll put in for Prior Authorization," I replied. "But your insurance may not cover it."

So he asked for samples. Then he asked for a prescription for Propecia. Then he asked about Botox and Restylane.

People's attitudes toward spending money can be hard to figure. Take Eunice, for example, who came by later the same day for me to remove a lesion on her shin that biopsy had shown to be a basal cell carcinoma. She showed me another spot on her arm.

"Could be the same thing," I said.

"The last biopsy cost me $127 after insurance," she said. "Must you biopsy this one, too?"

I told her that I must.

While I curetted her leg and arm, Eunice reported on her recent trip. "The cruise was fabulous," she said. "We've tried different lines, but Royal Flushing is the best. There are thousands of passengers, but you always feel like you're getting personal service."

"Where did you go?" I asked.

"Athens, the Greek islands, Rome, Venice. You know what the best part was—Lido. It's a small island near Venice, away from the tourists, very quiet, really lovely."

And not covered by health insurance, presumably.

So it's okay to spend money on Propecia, Botox, and Lido, but not on Protopic or a biopsy.

But the paradox is only apparent, not real. In fact, people divide the world in two: things you're supposed to pay for and things somebody else is supposed to pay for. What matters is not the size of the expenditure, but the category. How things get classified is a matter for economic anthropologists to figure out. But get classified they do.

I mention Chad and Eunice not just because they're fresh in my mind but because they're middle class. The kind of paradoxical economic behavior I'm describing is more often blamed on "welfare queens." Money for frivolities while stinting the essentials.

Not that I exempt myself from such attitudes. I confess to irritation when Mrs. Will Medicaid Cover This? tells me about her recent jaunt to somewhere tropical. The phenomenon, however, is not limited to the poor, or to the bourgeoisie, petty or haute, which brings me to the wealthy.

Gilbert drops by twice a year. He tells me about his efforts to raise funds for his alma mater, a venerable and well-endowed southern institute of higher learning of which he is very proud.

"We set a goal of $1.3 billion for our capital campaign," he told me recently. "But we're already over a billion, so we've raised the goal to $1.7 billion."

I would have whistled if I knew how.

Gilbert went on to tell me about recruitment. "You might think we wouldn't do this with competitors," he said, "But we recruit with a consortium of other universities from our neck of the woods. It's more economical that way.

"Someone messed up when the recruiters went out to Denver last year and didn't book the hall we use every year. So they called one of the local private prep schools and asked about using an auditorium. They said sure, but it was going to cost $1,800. Can you imagine?

"So we said, hey, there's this consortium of well-known southern schools coming to your place. Our being there will do a lot for your prestige.

"They agreed that it would, and they'd be delighted to have us, but for $1,800."

"What did you do?" I asked him.

Gilbert smiled. "I have some contacts out there." He said. "One of them is a charter member of the Presbyopia Hunt Club. We used their facility, which worked out fine. It cost us $750."

Money for endowments? Check. Money for buildings and grounds? Check. Money for salaries? Nah, I know too many professors and postdoctorates to think that's the case.

Now if I were going on grandly about 10-figure sums, I would be, well, embarrassed to brag about how I saved a grand off somebody's standard fee which they didn't have the sense to discount for the honor of serving me. But that's just me.

The point is that no single class has a monopoly on inscrutable economic behavior. One should therefore be understanding and sympathetic to all. But the flesh is weak, and some people are, for me at least, a little harder to sympathize with.

Chad sat on the exam table with an elegant black bag from Amphora, a local purveyor of high-end skin care products.

"I need a prescription for Protopic," he said.

"I'll put in for Prior Authorization," I replied. "But your insurance may not cover it."

So he asked for samples. Then he asked for a prescription for Propecia. Then he asked about Botox and Restylane.

People's attitudes toward spending money can be hard to figure. Take Eunice, for example, who came by later the same day for me to remove a lesion on her shin that biopsy had shown to be a basal cell carcinoma. She showed me another spot on her arm.

"Could be the same thing," I said.

"The last biopsy cost me $127 after insurance," she said. "Must you biopsy this one, too?"

I told her that I must.

While I curetted her leg and arm, Eunice reported on her recent trip. "The cruise was fabulous," she said. "We've tried different lines, but Royal Flushing is the best. There are thousands of passengers, but you always feel like you're getting personal service."

"Where did you go?" I asked.

"Athens, the Greek islands, Rome, Venice. You know what the best part was—Lido. It's a small island near Venice, away from the tourists, very quiet, really lovely."

And not covered by health insurance, presumably.

So it's okay to spend money on Propecia, Botox, and Lido, but not on Protopic or a biopsy.

But the paradox is only apparent, not real. In fact, people divide the world in two: things you're supposed to pay for and things somebody else is supposed to pay for. What matters is not the size of the expenditure, but the category. How things get classified is a matter for economic anthropologists to figure out. But get classified they do.

I mention Chad and Eunice not just because they're fresh in my mind but because they're middle class. The kind of paradoxical economic behavior I'm describing is more often blamed on "welfare queens." Money for frivolities while stinting the essentials.

Not that I exempt myself from such attitudes. I confess to irritation when Mrs. Will Medicaid Cover This? tells me about her recent jaunt to somewhere tropical. The phenomenon, however, is not limited to the poor, or to the bourgeoisie, petty or haute, which brings me to the wealthy.

Gilbert drops by twice a year. He tells me about his efforts to raise funds for his alma mater, a venerable and well-endowed southern institute of higher learning of which he is very proud.

"We set a goal of $1.3 billion for our capital campaign," he told me recently. "But we're already over a billion, so we've raised the goal to $1.7 billion."

I would have whistled if I knew how.

Gilbert went on to tell me about recruitment. "You might think we wouldn't do this with competitors," he said, "But we recruit with a consortium of other universities from our neck of the woods. It's more economical that way.

"Someone messed up when the recruiters went out to Denver last year and didn't book the hall we use every year. So they called one of the local private prep schools and asked about using an auditorium. They said sure, but it was going to cost $1,800. Can you imagine?

"So we said, hey, there's this consortium of well-known southern schools coming to your place. Our being there will do a lot for your prestige.

"They agreed that it would, and they'd be delighted to have us, but for $1,800."

"What did you do?" I asked him.

Gilbert smiled. "I have some contacts out there." He said. "One of them is a charter member of the Presbyopia Hunt Club. We used their facility, which worked out fine. It cost us $750."

Money for endowments? Check. Money for buildings and grounds? Check. Money for salaries? Nah, I know too many professors and postdoctorates to think that's the case.

Now if I were going on grandly about 10-figure sums, I would be, well, embarrassed to brag about how I saved a grand off somebody's standard fee which they didn't have the sense to discount for the honor of serving me. But that's just me.

The point is that no single class has a monopoly on inscrutable economic behavior. One should therefore be understanding and sympathetic to all. But the flesh is weak, and some people are, for me at least, a little harder to sympathize with.