Alan Rockoff

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.

"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.

There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.

This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.

We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")

Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.

For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.

Even light-related changes that have nothing to do with cancer—photosensitivity from doxycycline, for instance—cause concern, because "they came right after sun exposure."

Patients who have moles that look funny to them (like halo nevi)—or which someone has told them to "keep an eye on—may take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boom—moles cancerize.

Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.

The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:

"What are these crusty spots, Doctor?"

"Solar keratoses, Mrs. Goldfarb. They're from the sun."

"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")

Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.

Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.

Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.

No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.

Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.

"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.

There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.

This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.

We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")

Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.

For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.

Even light-related changes that have nothing to do with cancer—photosensitivity from doxycycline, for instance—cause concern, because "they came right after sun exposure."

Patients who have moles that look funny to them (like halo nevi)—or which someone has told them to "keep an eye on—may take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boom—moles cancerize.

Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.

The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:

"What are these crusty spots, Doctor?"

"Solar keratoses, Mrs. Goldfarb. They're from the sun."

"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")

Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.

Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.

Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.

No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.

Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.

"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.

There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.

This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.

We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")

Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.

For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.

Even light-related changes that have nothing to do with cancer—photosensitivity from doxycycline, for instance—cause concern, because "they came right after sun exposure."

Patients who have moles that look funny to them (like halo nevi)—or which someone has told them to "keep an eye on—may take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boom—moles cancerize.

Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.

The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:

"What are these crusty spots, Doctor?"

"Solar keratoses, Mrs. Goldfarb. They're from the sun."

"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")

Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.

Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.

Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.

No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.

Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."

You would think she was in grade school and had just gotten her report card. In a way, you'd be right.

Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.

How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.

If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.

But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.

Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.

Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.

This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.

▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.

▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.

▸ There is another basal cell, but you have fewer actinic keratoses than last time.

And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.

Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"

This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.

My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.

Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."

You would think she was in grade school and had just gotten her report card. In a way, you'd be right.

Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.

How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.

If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.

But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.

Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.

Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.

This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.

▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.

▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.

▸ There is another basal cell, but you have fewer actinic keratoses than last time.

And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.

Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"

This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.

My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.

Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."

You would think she was in grade school and had just gotten her report card. In a way, you'd be right.

Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.

How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.

If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.

But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.

Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.

Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.

This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.

▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.

▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.

▸ There is another basal cell, but you have fewer actinic keratoses than last time.

And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.

Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"

This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.

My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.

A recent news headline read: "Study Says Chatty Doctors Forget Patients."

"How are we today, Mr. Troldhaugen?"

"Well, doctor, I have this itch. You know, down below."

"Oh, don't I know it! I've been fighting that for years. Itch can drive you crazy. It's embarrassing too. I mean scratching in public is always awkward, but when you're a dermatologist … What have you been doing for it?"

"I have this fungus cream the druggist gave me."

"That figures. Fungus is usually the first thing everybody thinks of. I guess it could be a fungus, but if treating that does not work you have to think of other conditions. I had the same experience last time I tried to treat myself. I have all these samples, so I tried one. It was hard to remember to put it on twice a day—made me more sympathetic when my patients don't always follow instructions exactly the way I give them. Anyhow, after a while it got pretty obvious that I was going to need something different, so I took a different sample and sure enough that did the trick."

"Maybe you can prescribe that for me."

"It's interesting how common these symptoms are. People often come over to me outside the office to ask pretty much the same questions, about itch and rashes and so forth. Of course, I can't exactly examine them there in the street, but I can get a pretty good idea of what they have and what they need. After all, I've had the same symptoms myself."

"So, doctor, what would you recommend?"

"And sometimes I've tried to share my experiences when I've had the same things as my patients do, just to show them that their situation isn't as strange or as frustrating as they might have thought. Take my wart, for instance …"

"But I don't have a wart."

"I had a wart on my left thumb. Now that's interesting right there, because I'm right-handed. People always assume that warts are a virus so they must be contagious, but if they were—and I certainly shake hands with a lot of wart patients every day—why would they spread to my left thumb? But in any case it took me 4 years to get rid of mine, even though I have liquid nitrogen so I can freeze myself anytime I want, and I did too. So I used to tell that to people with resistant warts, so they wouldn't feel quite so frustrated."

"Doctor …"

"And you know what? I found that people really didn't want to know about my problems, whether they were the same kind as they had or not. In fact, patients weren't all that interested in what was going on with me in general. Of course, there are some people who've been seeing me for almost 30 years, who are old friends by now. They know the names of my grandchildren and ask after them, that sort of thing. But most other patients don't really want to know what I've been up to, where I'm going on vacation, or what staffing and administrative hassles I'm dealing with. Which kind of seems right, when you consider that they've come not to find out what's wrong with me, but what's wrong with them. Doesn't that make sense?"

"Yes, but …"

"And then I read in the paper that they did this study in Rochester, with hidden mikes or something, and they found out that doctors were gabbing about their own weight problems and exercise programs, apparently with the thought that this would produce greater rapport. Instead, when the doctors heard tapes of what they said, they realized that maybe not 100% of the time, but most of the time talking about themselves had more to do with the doctors than with the patients. Can you believe that?"

"To tell the truth, I can."

"It's amazing how people can see faults in other people but not notice it in themselves. Isn't that right, Mr. Trondheim?"

"Troldhaugen."

"Right. Well, it's been nice chatting with you. Did I give you the prescription?"

A recent news headline read: "Study Says Chatty Doctors Forget Patients."

"How are we today, Mr. Troldhaugen?"

"Well, doctor, I have this itch. You know, down below."

"Oh, don't I know it! I've been fighting that for years. Itch can drive you crazy. It's embarrassing too. I mean scratching in public is always awkward, but when you're a dermatologist … What have you been doing for it?"

"I have this fungus cream the druggist gave me."

"That figures. Fungus is usually the first thing everybody thinks of. I guess it could be a fungus, but if treating that does not work you have to think of other conditions. I had the same experience last time I tried to treat myself. I have all these samples, so I tried one. It was hard to remember to put it on twice a day—made me more sympathetic when my patients don't always follow instructions exactly the way I give them. Anyhow, after a while it got pretty obvious that I was going to need something different, so I took a different sample and sure enough that did the trick."

"Maybe you can prescribe that for me."

"It's interesting how common these symptoms are. People often come over to me outside the office to ask pretty much the same questions, about itch and rashes and so forth. Of course, I can't exactly examine them there in the street, but I can get a pretty good idea of what they have and what they need. After all, I've had the same symptoms myself."

"So, doctor, what would you recommend?"

"And sometimes I've tried to share my experiences when I've had the same things as my patients do, just to show them that their situation isn't as strange or as frustrating as they might have thought. Take my wart, for instance …"

"But I don't have a wart."

"I had a wart on my left thumb. Now that's interesting right there, because I'm right-handed. People always assume that warts are a virus so they must be contagious, but if they were—and I certainly shake hands with a lot of wart patients every day—why would they spread to my left thumb? But in any case it took me 4 years to get rid of mine, even though I have liquid nitrogen so I can freeze myself anytime I want, and I did too. So I used to tell that to people with resistant warts, so they wouldn't feel quite so frustrated."

"Doctor …"

"And you know what? I found that people really didn't want to know about my problems, whether they were the same kind as they had or not. In fact, patients weren't all that interested in what was going on with me in general. Of course, there are some people who've been seeing me for almost 30 years, who are old friends by now. They know the names of my grandchildren and ask after them, that sort of thing. But most other patients don't really want to know what I've been up to, where I'm going on vacation, or what staffing and administrative hassles I'm dealing with. Which kind of seems right, when you consider that they've come not to find out what's wrong with me, but what's wrong with them. Doesn't that make sense?"

"Yes, but …"

"And then I read in the paper that they did this study in Rochester, with hidden mikes or something, and they found out that doctors were gabbing about their own weight problems and exercise programs, apparently with the thought that this would produce greater rapport. Instead, when the doctors heard tapes of what they said, they realized that maybe not 100% of the time, but most of the time talking about themselves had more to do with the doctors than with the patients. Can you believe that?"

"To tell the truth, I can."

"It's amazing how people can see faults in other people but not notice it in themselves. Isn't that right, Mr. Trondheim?"

"Troldhaugen."

"Right. Well, it's been nice chatting with you. Did I give you the prescription?"

A recent news headline read: "Study Says Chatty Doctors Forget Patients."

"How are we today, Mr. Troldhaugen?"

"Well, doctor, I have this itch. You know, down below."

"Oh, don't I know it! I've been fighting that for years. Itch can drive you crazy. It's embarrassing too. I mean scratching in public is always awkward, but when you're a dermatologist … What have you been doing for it?"

"I have this fungus cream the druggist gave me."

"That figures. Fungus is usually the first thing everybody thinks of. I guess it could be a fungus, but if treating that does not work you have to think of other conditions. I had the same experience last time I tried to treat myself. I have all these samples, so I tried one. It was hard to remember to put it on twice a day—made me more sympathetic when my patients don't always follow instructions exactly the way I give them. Anyhow, after a while it got pretty obvious that I was going to need something different, so I took a different sample and sure enough that did the trick."

"Maybe you can prescribe that for me."

"It's interesting how common these symptoms are. People often come over to me outside the office to ask pretty much the same questions, about itch and rashes and so forth. Of course, I can't exactly examine them there in the street, but I can get a pretty good idea of what they have and what they need. After all, I've had the same symptoms myself."

"So, doctor, what would you recommend?"

"And sometimes I've tried to share my experiences when I've had the same things as my patients do, just to show them that their situation isn't as strange or as frustrating as they might have thought. Take my wart, for instance …"

"But I don't have a wart."

"I had a wart on my left thumb. Now that's interesting right there, because I'm right-handed. People always assume that warts are a virus so they must be contagious, but if they were—and I certainly shake hands with a lot of wart patients every day—why would they spread to my left thumb? But in any case it took me 4 years to get rid of mine, even though I have liquid nitrogen so I can freeze myself anytime I want, and I did too. So I used to tell that to people with resistant warts, so they wouldn't feel quite so frustrated."

"Doctor …"

"And you know what? I found that people really didn't want to know about my problems, whether they were the same kind as they had or not. In fact, patients weren't all that interested in what was going on with me in general. Of course, there are some people who've been seeing me for almost 30 years, who are old friends by now. They know the names of my grandchildren and ask after them, that sort of thing. But most other patients don't really want to know what I've been up to, where I'm going on vacation, or what staffing and administrative hassles I'm dealing with. Which kind of seems right, when you consider that they've come not to find out what's wrong with me, but what's wrong with them. Doesn't that make sense?"

"Yes, but …"

"And then I read in the paper that they did this study in Rochester, with hidden mikes or something, and they found out that doctors were gabbing about their own weight problems and exercise programs, apparently with the thought that this would produce greater rapport. Instead, when the doctors heard tapes of what they said, they realized that maybe not 100% of the time, but most of the time talking about themselves had more to do with the doctors than with the patients. Can you believe that?"

"To tell the truth, I can."

"It's amazing how people can see faults in other people but not notice it in themselves. Isn't that right, Mr. Trondheim?"

"Troldhaugen."

"Right. Well, it's been nice chatting with you. Did I give you the prescription?"

Call me callous, but Sybil really did look like a lizard. Lifelong eczema had turned her face an alarming reddish-purple. Scabs covered her hands. It didn't help that her job as a pharmacist put her in daily contact with dozens of people.

"We haven't seen you in a while," I said. "How often do you use your triamcinolone?"

"I don't use it," she said. "I'm afraid of atrophy."

"You've had a couple of courses of oral antibiotics," I said, "and one of your doctors suggested cyclosporine. Let's try the triamcinolone four times a day for a week, just to see what happens."

Sybil agreed.

A week later Sybil was back, with a big smile on a face now several shades lighter. Her hands were almost healed, too. Medicines work so much better when you use them.

"Do your customers make comments about your eczema when it's out of control?" I asked.

"You bet," said Sybil. "Last week I was giving a man a bottle of hydroxyzine. He looked at my hands and said, 'Take those pills back. I'm not swallowing them if you touched them.'"

Patients with visible disease report that kind of hurtful remark all the time. Although it's easy to be critical of people tactless enough to talk that way, perhaps we should be more understanding of why they do. Though it's just speculation, I have a theory.

Back in 1994, I leased my first pulsed-dye laser, the kind that left deep purple bruises for 10–14 days. Despite counseling showing photos of what to expect, and guaranteeing that the purpura always goes away, patients routinely dissolved into whimpering puddles when they saw what they looked like right after treatment.

One day, Marilyn asked me to treat her facial telangiectases. "I need to stay afterward to apply makeup," she said. "I train monkeys for the blind. If they see me with spots on my face, they'll get upset and start pointing."

That sounded a lot like my patients. I called Marilyn's supervisor to talk this over, but she wasn't interested since I'm not in her field. I asked a friend who teaches biology to put me in touch with his university's primate research center. Such centers don't publish their contact information, fearful of animal rights activists bent on blowing them up.

The Ph.D. student who called me sounded apprehensive. "Who are you?" he whispered.

"Just a dermatologist," I explained. "I was wondering whether this tendency to point agitatedly at red spots might be part of primate behavior that people and monkeys share."

"Are you writing a paper?" he asked. I explained that I was just interested. This threw him a bit, but he promised to send me some references, which turned out to be off point.

I therefore offer only an experienced hunch, but it seems to me that pointing out obvious spots, marks, and other visible but unexpected changes on other humans is a basic impulse. The veneer of civilized tact that helps us suppress this urge often peels right off. Consider how you feel when the person sitting across from you has a piece of food dangling from her lip. Don't you feel overwhelmed with the need to flick it off, or at least point it out? How come?

If you see a shiner on someone's eye, why is it so hard to suppress the compulsion to say, "Look, look, you have a bruise on your eye!" (As though he didn't already know it.) Somehow, redness seems to be a source of special alarm. Ruddy people are routinely greeted with cries of, "You're all red! Are you all right?!" That's perhaps a big reason people find rosacea, which ought to be trivial, so disturbing; pointing with alarm at your own face can't be much fun.

It seems to me that this instinctive impulse is what drives people to point out to others lumps and bumps, dark spots, rashes, and any number of other visible symptoms (coughs, limps, tremors, and so on.) Sometimes this helps get people to seek the help they need. Most other times it's just embarrassing, leaving the pointee feeling stigmatized and ashamed.

People like Sybil will never look entirely normal. We can't stop people from commenting on her appearance, just as we can't prevent pool attendants and fellow swimmers from handing out hurtful guff to patients with widespread psoriasis. Education goes only a short way, whether with humans or our simian cousins.

If we can, it's perhaps better to make her skin change as invisibly as possible so there's nothing to point at.

Sometimes treatment helps people, especially if they use it.

Call me callous, but Sybil really did look like a lizard. Lifelong eczema had turned her face an alarming reddish-purple. Scabs covered her hands. It didn't help that her job as a pharmacist put her in daily contact with dozens of people.

"We haven't seen you in a while," I said. "How often do you use your triamcinolone?"

"I don't use it," she said. "I'm afraid of atrophy."

"You've had a couple of courses of oral antibiotics," I said, "and one of your doctors suggested cyclosporine. Let's try the triamcinolone four times a day for a week, just to see what happens."

Sybil agreed.

A week later Sybil was back, with a big smile on a face now several shades lighter. Her hands were almost healed, too. Medicines work so much better when you use them.

"Do your customers make comments about your eczema when it's out of control?" I asked.

"You bet," said Sybil. "Last week I was giving a man a bottle of hydroxyzine. He looked at my hands and said, 'Take those pills back. I'm not swallowing them if you touched them.'"

Patients with visible disease report that kind of hurtful remark all the time. Although it's easy to be critical of people tactless enough to talk that way, perhaps we should be more understanding of why they do. Though it's just speculation, I have a theory.

Back in 1994, I leased my first pulsed-dye laser, the kind that left deep purple bruises for 10–14 days. Despite counseling showing photos of what to expect, and guaranteeing that the purpura always goes away, patients routinely dissolved into whimpering puddles when they saw what they looked like right after treatment.

One day, Marilyn asked me to treat her facial telangiectases. "I need to stay afterward to apply makeup," she said. "I train monkeys for the blind. If they see me with spots on my face, they'll get upset and start pointing."

That sounded a lot like my patients. I called Marilyn's supervisor to talk this over, but she wasn't interested since I'm not in her field. I asked a friend who teaches biology to put me in touch with his university's primate research center. Such centers don't publish their contact information, fearful of animal rights activists bent on blowing them up.

The Ph.D. student who called me sounded apprehensive. "Who are you?" he whispered.

"Just a dermatologist," I explained. "I was wondering whether this tendency to point agitatedly at red spots might be part of primate behavior that people and monkeys share."

"Are you writing a paper?" he asked. I explained that I was just interested. This threw him a bit, but he promised to send me some references, which turned out to be off point.

I therefore offer only an experienced hunch, but it seems to me that pointing out obvious spots, marks, and other visible but unexpected changes on other humans is a basic impulse. The veneer of civilized tact that helps us suppress this urge often peels right off. Consider how you feel when the person sitting across from you has a piece of food dangling from her lip. Don't you feel overwhelmed with the need to flick it off, or at least point it out? How come?

If you see a shiner on someone's eye, why is it so hard to suppress the compulsion to say, "Look, look, you have a bruise on your eye!" (As though he didn't already know it.) Somehow, redness seems to be a source of special alarm. Ruddy people are routinely greeted with cries of, "You're all red! Are you all right?!" That's perhaps a big reason people find rosacea, which ought to be trivial, so disturbing; pointing with alarm at your own face can't be much fun.

It seems to me that this instinctive impulse is what drives people to point out to others lumps and bumps, dark spots, rashes, and any number of other visible symptoms (coughs, limps, tremors, and so on.) Sometimes this helps get people to seek the help they need. Most other times it's just embarrassing, leaving the pointee feeling stigmatized and ashamed.

People like Sybil will never look entirely normal. We can't stop people from commenting on her appearance, just as we can't prevent pool attendants and fellow swimmers from handing out hurtful guff to patients with widespread psoriasis. Education goes only a short way, whether with humans or our simian cousins.

If we can, it's perhaps better to make her skin change as invisibly as possible so there's nothing to point at.

Sometimes treatment helps people, especially if they use it.

Call me callous, but Sybil really did look like a lizard. Lifelong eczema had turned her face an alarming reddish-purple. Scabs covered her hands. It didn't help that her job as a pharmacist put her in daily contact with dozens of people.

"We haven't seen you in a while," I said. "How often do you use your triamcinolone?"

"I don't use it," she said. "I'm afraid of atrophy."

"You've had a couple of courses of oral antibiotics," I said, "and one of your doctors suggested cyclosporine. Let's try the triamcinolone four times a day for a week, just to see what happens."

Sybil agreed.

A week later Sybil was back, with a big smile on a face now several shades lighter. Her hands were almost healed, too. Medicines work so much better when you use them.

"Do your customers make comments about your eczema when it's out of control?" I asked.

"You bet," said Sybil. "Last week I was giving a man a bottle of hydroxyzine. He looked at my hands and said, 'Take those pills back. I'm not swallowing them if you touched them.'"

Patients with visible disease report that kind of hurtful remark all the time. Although it's easy to be critical of people tactless enough to talk that way, perhaps we should be more understanding of why they do. Though it's just speculation, I have a theory.

Back in 1994, I leased my first pulsed-dye laser, the kind that left deep purple bruises for 10–14 days. Despite counseling showing photos of what to expect, and guaranteeing that the purpura always goes away, patients routinely dissolved into whimpering puddles when they saw what they looked like right after treatment.

One day, Marilyn asked me to treat her facial telangiectases. "I need to stay afterward to apply makeup," she said. "I train monkeys for the blind. If they see me with spots on my face, they'll get upset and start pointing."

That sounded a lot like my patients. I called Marilyn's supervisor to talk this over, but she wasn't interested since I'm not in her field. I asked a friend who teaches biology to put me in touch with his university's primate research center. Such centers don't publish their contact information, fearful of animal rights activists bent on blowing them up.

The Ph.D. student who called me sounded apprehensive. "Who are you?" he whispered.

"Just a dermatologist," I explained. "I was wondering whether this tendency to point agitatedly at red spots might be part of primate behavior that people and monkeys share."

"Are you writing a paper?" he asked. I explained that I was just interested. This threw him a bit, but he promised to send me some references, which turned out to be off point.

I therefore offer only an experienced hunch, but it seems to me that pointing out obvious spots, marks, and other visible but unexpected changes on other humans is a basic impulse. The veneer of civilized tact that helps us suppress this urge often peels right off. Consider how you feel when the person sitting across from you has a piece of food dangling from her lip. Don't you feel overwhelmed with the need to flick it off, or at least point it out? How come?

If you see a shiner on someone's eye, why is it so hard to suppress the compulsion to say, "Look, look, you have a bruise on your eye!" (As though he didn't already know it.) Somehow, redness seems to be a source of special alarm. Ruddy people are routinely greeted with cries of, "You're all red! Are you all right?!" That's perhaps a big reason people find rosacea, which ought to be trivial, so disturbing; pointing with alarm at your own face can't be much fun.

It seems to me that this instinctive impulse is what drives people to point out to others lumps and bumps, dark spots, rashes, and any number of other visible symptoms (coughs, limps, tremors, and so on.) Sometimes this helps get people to seek the help they need. Most other times it's just embarrassing, leaving the pointee feeling stigmatized and ashamed.

People like Sybil will never look entirely normal. We can't stop people from commenting on her appearance, just as we can't prevent pool attendants and fellow swimmers from handing out hurtful guff to patients with widespread psoriasis. Education goes only a short way, whether with humans or our simian cousins.

If we can, it's perhaps better to make her skin change as invisibly as possible so there's nothing to point at.

Sometimes treatment helps people, especially if they use it.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

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

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

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

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

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

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

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

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

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

"When will he return?" asked Gregory.

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

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

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

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

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

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

"What is an ETG?" asked Gregory.

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

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

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

"Where is their office?" asked Gregory.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"When will he return?" asked Gregory.

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

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

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

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

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

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

"What is an ETG?" asked Gregory.

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

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

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

"Where is their office?" asked Gregory.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

"When will he return?" asked Gregory.

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

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

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

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

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

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

"What is an ETG?" asked Gregory.

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

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

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

"Where is their office?" asked Gregory.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis of the Goji sales approach shows several elements:

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis of the Goji sales approach shows several elements:

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

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

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

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

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

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

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

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

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

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

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

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

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

Analysis of the Goji sales approach shows several elements:

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

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

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

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

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

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

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

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