Cold Iron Truth

“We cannot teach people to withhold judgment; judgments are embedded in the way we view objects. I do not see a “tree”; I see a pleasant or an ugly tree. It is not possible without great, paralyzing effort to strip these small values we attach to matters. Likewise, it is not possible to hold a situation in one’s head without some element of bias” – Nassim Nicholas Taleb, MBA, PhD, “The Black Swan.”

Each morning I see the hungry ghosts congregate at the end of the alley behind my office waiting for their addiction clinic appointments (Maté G. “In the Realm of Hungry Ghosts, Close Encounters with Addiction” Berkeley, Calif.: North Atlantic Books, 2008). The fast food restaurant and the convenience store won’t let them linger, so there they sit on the curb in the saddest magpie’s row in the world. They have lip, nose, and eyebrow piercings, and lightning bolts tattooed up their cheeks. They all have backpacks, a few even rolling suitcases. They are opioid addicts, and almost all young, White adults. There they sit, once-innocent young girls, now worn and hardened, and vicious-looking young men, all with downcast empty eyes and miserable expressions. They are a frightening group marginalized by their addiction.
 

Opioid addiction became a national focus of attention with clarion calls for treatment, which resulted in legislative funding for treatment, restrictions on prescribing, and readily available Narcan. Physicians have greatly reduced their prescribing of narcotics and overdose death rates have dropped, but the drug crisis has not gone away, it has only been recently overshadowed by COVID-19.

The most ironic part of the current opioid epidemic and overdose deaths, and the other three bloodborne horsemen of death – endocarditis; hepatitis B, C, and D; and HIV – was that these scourges were affecting the Black community 40 years ago when, in my view, no one seemed to care. There was no addiction counseling, no treatment centers, and law enforcement would visit only with hopes of making a dealer’s arrest. Not until it became a White suburban issue, did this public health problem become recognized as something to act on. This is of course a result of racism, but there is a broader lesson here.

Humans may be naturally bigoted toward any marginalized or minority group. I recall working in the HIV clinic (before it was called HIV) in Dallas in the mid-1980s. The county refused to pay for zidovudine, which was very expensive at the time, and was sued to supply medication for a group marginalized by their sexual orientation. The AIDS epidemic was initially ignored, with the virus spreading to intravenous drug users and eventually to the broader population, which is when effective treatments became a priority.

Physicians and society should pay close attention to the ills of our marginalized communities. Because of isolation from health care, they are the medical canaries in the coal mine for all of us. Medical issues and infectious diseases identified there should be a priority and solutions sought and applied. This not only would benefit the marginalized group and ease their suffering, but would be salutary to society as a whole, because they surely will be coming everyone’s way.

COVID-19 highlights this. The working poor live in close quarters and most rely on crowded public transportation, and so a respiratory illness spreads rapidly in a population that cannot practically physically distance and probably cannot afford face masks, or alcohol hand gel.

As noted above, we have a persistent illegal drug epidemic. We also have a resurgence in venereal disease and tuberculosis, much of it drug resistant, which again is concentrated in our marginalized populations. Meanwhile, we have been cutting spending on public health, while we obviously need more resources devoted to public and community health.

When we step back and look, there are public health issues everywhere. We could eliminate 90% of cervical cancer and most of the oropharyngeal cancer with use of a very effective vaccine, but we struggle to get it paid for and to convince the public of its ultimate good.

Another example is in Ohio, where we raised the age to purchase tobacco to 21, which is laudable. But children of any age can still access tanning beds, which dramatically raises their lifetime risk of melanoma, often using a note from their “parents” that they write for each other on the car hood in the strip mall parking lot. This group of mostly young white women could also be considered a marginalized group despite their disposable income because of their belief in personal invincibility and false impressions of a tan conferring beauty and vitality repeated endlessly in their echo chamber of social media impressions.

Perhaps we should gauge the state of our public health by the health status of the most oppressed group of all, the incarcerated. Is it really possible that we don’t routinely test for and treat hepatitis C in many of our prisons? Is this indifference because the incarcerated are again a largely minority group and hepatitis C is spread by intravenous drug use?

Solutions and interventions for these problems range widely in cost, but all would eventually save the greater society money and alleviate great misery for those affected.

Perhaps we should be talking about the decriminalization of drug use. The drugs are already here and the consequences apparent, including overflowing prisons and out of control gun violence. This is a much thornier discussion, but seems at the root of many of our problems.

Bigotry is insidious and will take a long and continuing active effort to combat. As Dr. Taleb notes in the introductory quote, it requires a constant, tiring, deliberate mental effort to be mindful of one’s biases. As physicians, we have always been careful to try and treat all patients without bias, but this is not enough. We must become more insistent about the funding and application of public health measures.

Recognizing and treating the medical problems of our marginalized populations seems a doable first step while our greater society struggles with mental bias toward marginalized groups. Reducing the health burdens of these groups can only help them in their life struggles and will benefit all.

Someone once told me that the cold wind in the ghetto eventually blows out into the suburbs, and they were right. As physicians and a society, we should be insistent about correcting medical injustices beforehand. Let’s get started.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]

“We cannot teach people to withhold judgment; judgments are embedded in the way we view objects. I do not see a “tree”; I see a pleasant or an ugly tree. It is not possible without great, paralyzing effort to strip these small values we attach to matters. Likewise, it is not possible to hold a situation in one’s head without some element of bias” – Nassim Nicholas Taleb, MBA, PhD, “The Black Swan.”

Each morning I see the hungry ghosts congregate at the end of the alley behind my office waiting for their addiction clinic appointments (Maté G. “In the Realm of Hungry Ghosts, Close Encounters with Addiction” Berkeley, Calif.: North Atlantic Books, 2008). The fast food restaurant and the convenience store won’t let them linger, so there they sit on the curb in the saddest magpie’s row in the world. They have lip, nose, and eyebrow piercings, and lightning bolts tattooed up their cheeks. They all have backpacks, a few even rolling suitcases. They are opioid addicts, and almost all young, White adults. There they sit, once-innocent young girls, now worn and hardened, and vicious-looking young men, all with downcast empty eyes and miserable expressions. They are a frightening group marginalized by their addiction.
 

Opioid addiction became a national focus of attention with clarion calls for treatment, which resulted in legislative funding for treatment, restrictions on prescribing, and readily available Narcan. Physicians have greatly reduced their prescribing of narcotics and overdose death rates have dropped, but the drug crisis has not gone away, it has only been recently overshadowed by COVID-19.

The most ironic part of the current opioid epidemic and overdose deaths, and the other three bloodborne horsemen of death – endocarditis; hepatitis B, C, and D; and HIV – was that these scourges were affecting the Black community 40 years ago when, in my view, no one seemed to care. There was no addiction counseling, no treatment centers, and law enforcement would visit only with hopes of making a dealer’s arrest. Not until it became a White suburban issue, did this public health problem become recognized as something to act on. This is of course a result of racism, but there is a broader lesson here.

Humans may be naturally bigoted toward any marginalized or minority group. I recall working in the HIV clinic (before it was called HIV) in Dallas in the mid-1980s. The county refused to pay for zidovudine, which was very expensive at the time, and was sued to supply medication for a group marginalized by their sexual orientation. The AIDS epidemic was initially ignored, with the virus spreading to intravenous drug users and eventually to the broader population, which is when effective treatments became a priority.

Physicians and society should pay close attention to the ills of our marginalized communities. Because of isolation from health care, they are the medical canaries in the coal mine for all of us. Medical issues and infectious diseases identified there should be a priority and solutions sought and applied. This not only would benefit the marginalized group and ease their suffering, but would be salutary to society as a whole, because they surely will be coming everyone’s way.

COVID-19 highlights this. The working poor live in close quarters and most rely on crowded public transportation, and so a respiratory illness spreads rapidly in a population that cannot practically physically distance and probably cannot afford face masks, or alcohol hand gel.

As noted above, we have a persistent illegal drug epidemic. We also have a resurgence in venereal disease and tuberculosis, much of it drug resistant, which again is concentrated in our marginalized populations. Meanwhile, we have been cutting spending on public health, while we obviously need more resources devoted to public and community health.

When we step back and look, there are public health issues everywhere. We could eliminate 90% of cervical cancer and most of the oropharyngeal cancer with use of a very effective vaccine, but we struggle to get it paid for and to convince the public of its ultimate good.

Another example is in Ohio, where we raised the age to purchase tobacco to 21, which is laudable. But children of any age can still access tanning beds, which dramatically raises their lifetime risk of melanoma, often using a note from their “parents” that they write for each other on the car hood in the strip mall parking lot. This group of mostly young white women could also be considered a marginalized group despite their disposable income because of their belief in personal invincibility and false impressions of a tan conferring beauty and vitality repeated endlessly in their echo chamber of social media impressions.

Perhaps we should gauge the state of our public health by the health status of the most oppressed group of all, the incarcerated. Is it really possible that we don’t routinely test for and treat hepatitis C in many of our prisons? Is this indifference because the incarcerated are again a largely minority group and hepatitis C is spread by intravenous drug use?

Solutions and interventions for these problems range widely in cost, but all would eventually save the greater society money and alleviate great misery for those affected.

Perhaps we should be talking about the decriminalization of drug use. The drugs are already here and the consequences apparent, including overflowing prisons and out of control gun violence. This is a much thornier discussion, but seems at the root of many of our problems.

Bigotry is insidious and will take a long and continuing active effort to combat. As Dr. Taleb notes in the introductory quote, it requires a constant, tiring, deliberate mental effort to be mindful of one’s biases. As physicians, we have always been careful to try and treat all patients without bias, but this is not enough. We must become more insistent about the funding and application of public health measures.

Recognizing and treating the medical problems of our marginalized populations seems a doable first step while our greater society struggles with mental bias toward marginalized groups. Reducing the health burdens of these groups can only help them in their life struggles and will benefit all.

Someone once told me that the cold wind in the ghetto eventually blows out into the suburbs, and they were right. As physicians and a society, we should be insistent about correcting medical injustices beforehand. Let’s get started.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]

“We cannot teach people to withhold judgment; judgments are embedded in the way we view objects. I do not see a “tree”; I see a pleasant or an ugly tree. It is not possible without great, paralyzing effort to strip these small values we attach to matters. Likewise, it is not possible to hold a situation in one’s head without some element of bias” – Nassim Nicholas Taleb, MBA, PhD, “The Black Swan.”

Each morning I see the hungry ghosts congregate at the end of the alley behind my office waiting for their addiction clinic appointments (Maté G. “In the Realm of Hungry Ghosts, Close Encounters with Addiction” Berkeley, Calif.: North Atlantic Books, 2008). The fast food restaurant and the convenience store won’t let them linger, so there they sit on the curb in the saddest magpie’s row in the world. They have lip, nose, and eyebrow piercings, and lightning bolts tattooed up their cheeks. They all have backpacks, a few even rolling suitcases. They are opioid addicts, and almost all young, White adults. There they sit, once-innocent young girls, now worn and hardened, and vicious-looking young men, all with downcast empty eyes and miserable expressions. They are a frightening group marginalized by their addiction.
 

Opioid addiction became a national focus of attention with clarion calls for treatment, which resulted in legislative funding for treatment, restrictions on prescribing, and readily available Narcan. Physicians have greatly reduced their prescribing of narcotics and overdose death rates have dropped, but the drug crisis has not gone away, it has only been recently overshadowed by COVID-19.

The most ironic part of the current opioid epidemic and overdose deaths, and the other three bloodborne horsemen of death – endocarditis; hepatitis B, C, and D; and HIV – was that these scourges were affecting the Black community 40 years ago when, in my view, no one seemed to care. There was no addiction counseling, no treatment centers, and law enforcement would visit only with hopes of making a dealer’s arrest. Not until it became a White suburban issue, did this public health problem become recognized as something to act on. This is of course a result of racism, but there is a broader lesson here.

Humans may be naturally bigoted toward any marginalized or minority group. I recall working in the HIV clinic (before it was called HIV) in Dallas in the mid-1980s. The county refused to pay for zidovudine, which was very expensive at the time, and was sued to supply medication for a group marginalized by their sexual orientation. The AIDS epidemic was initially ignored, with the virus spreading to intravenous drug users and eventually to the broader population, which is when effective treatments became a priority.

Physicians and society should pay close attention to the ills of our marginalized communities. Because of isolation from health care, they are the medical canaries in the coal mine for all of us. Medical issues and infectious diseases identified there should be a priority and solutions sought and applied. This not only would benefit the marginalized group and ease their suffering, but would be salutary to society as a whole, because they surely will be coming everyone’s way.

COVID-19 highlights this. The working poor live in close quarters and most rely on crowded public transportation, and so a respiratory illness spreads rapidly in a population that cannot practically physically distance and probably cannot afford face masks, or alcohol hand gel.

As noted above, we have a persistent illegal drug epidemic. We also have a resurgence in venereal disease and tuberculosis, much of it drug resistant, which again is concentrated in our marginalized populations. Meanwhile, we have been cutting spending on public health, while we obviously need more resources devoted to public and community health.

When we step back and look, there are public health issues everywhere. We could eliminate 90% of cervical cancer and most of the oropharyngeal cancer with use of a very effective vaccine, but we struggle to get it paid for and to convince the public of its ultimate good.

Another example is in Ohio, where we raised the age to purchase tobacco to 21, which is laudable. But children of any age can still access tanning beds, which dramatically raises their lifetime risk of melanoma, often using a note from their “parents” that they write for each other on the car hood in the strip mall parking lot. This group of mostly young white women could also be considered a marginalized group despite their disposable income because of their belief in personal invincibility and false impressions of a tan conferring beauty and vitality repeated endlessly in their echo chamber of social media impressions.

Perhaps we should gauge the state of our public health by the health status of the most oppressed group of all, the incarcerated. Is it really possible that we don’t routinely test for and treat hepatitis C in many of our prisons? Is this indifference because the incarcerated are again a largely minority group and hepatitis C is spread by intravenous drug use?

Solutions and interventions for these problems range widely in cost, but all would eventually save the greater society money and alleviate great misery for those affected.

Perhaps we should be talking about the decriminalization of drug use. The drugs are already here and the consequences apparent, including overflowing prisons and out of control gun violence. This is a much thornier discussion, but seems at the root of many of our problems.

Bigotry is insidious and will take a long and continuing active effort to combat. As Dr. Taleb notes in the introductory quote, it requires a constant, tiring, deliberate mental effort to be mindful of one’s biases. As physicians, we have always been careful to try and treat all patients without bias, but this is not enough. We must become more insistent about the funding and application of public health measures.

Recognizing and treating the medical problems of our marginalized populations seems a doable first step while our greater society struggles with mental bias toward marginalized groups. Reducing the health burdens of these groups can only help them in their life struggles and will benefit all.

Someone once told me that the cold wind in the ghetto eventually blows out into the suburbs, and they were right. As physicians and a society, we should be insistent about correcting medical injustices beforehand. Let’s get started.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]

Grandma Exie used to tell a story about her grandmother on her father’s side, who lived in northeastern Arkansas. Towards the end of the Civil War, Northern and Southern troops were expected to “live off the land,” and both sides had torn through her poor dirt farm and carried off all the livestock and crops. The only thing they didn’t take was her bull mastiff, who was a pretty fair hunting and guard dog. Starving, she had no other option than to pack up and head east for Tennessee, where her husband was stationed with Joseph Hooker’s army. Many thousands of destitute women and children, most of whom were related to one of the troops, followed the army, where some of the army’s rations could be shared with them.

She headed out on foot and all went well until day 3 or so, when a panther attacked them, but she, armed with a branch, and her loyal dog were able to drive it off. The panther followed them for 3 days while she hid in a tree at night with her dog at the foot of a tree. Eventually, the panther gave up and she made it to Tennessee to safety.

Grandma Exie said her grandmother had “grit” and used this story whenever any of us would complain about how hard times were or how we were mistreated.

It is time for all of us to buck up and show a little grit in the face of a viral pandemic and social unrest. The answers are not easy or clear, but our health care system and our nation have faced much greater challenges. The 1918 flu pandemic was much more devastating, killing millions worldwide, and recall, 620,000 died in the Civil War, more than all other American wars combined. There is a deep seam of grit and resilience in Americans. We don’t always get it right immediately, but we usually do in the end.

The protests are justifiable outrage over police brutality, fueled by a high unemployment rate, both of which are a cause for frustration. The looting and destruction appears to be opportunistic thievery and some organized vandalization in my opinion. Most of the damage caused by riots and looting is not covered by insurance, and this will be a death blow to many small businesses already facing major financial setbacks as customers have stayed home for months and laying off staff has become necessary.

As for the impact on our practices, most physicians have been lucky and not been looted or burned out. Most of us have resumed practice, at least in a limited fashion, wearing masks; keeping the waiting room mostly empty; using social distancing and hand, air, and surface disinfection. In most of the country, the disease incidence has become lower, and the risk of not seeing the doctor is now greater than catching COVID-19.

So show grit, be careful, be vigilant, and practice your profession. Support your local small businesses, particularly if they have been the victims of senseless violence. We will work our way through these times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He had no disclosures related to this column. Write to him at [email protected].

Grandma Exie used to tell a story about her grandmother on her father’s side, who lived in northeastern Arkansas. Towards the end of the Civil War, Northern and Southern troops were expected to “live off the land,” and both sides had torn through her poor dirt farm and carried off all the livestock and crops. The only thing they didn’t take was her bull mastiff, who was a pretty fair hunting and guard dog. Starving, she had no other option than to pack up and head east for Tennessee, where her husband was stationed with Joseph Hooker’s army. Many thousands of destitute women and children, most of whom were related to one of the troops, followed the army, where some of the army’s rations could be shared with them.

She headed out on foot and all went well until day 3 or so, when a panther attacked them, but she, armed with a branch, and her loyal dog were able to drive it off. The panther followed them for 3 days while she hid in a tree at night with her dog at the foot of a tree. Eventually, the panther gave up and she made it to Tennessee to safety.

Grandma Exie said her grandmother had “grit” and used this story whenever any of us would complain about how hard times were or how we were mistreated.

It is time for all of us to buck up and show a little grit in the face of a viral pandemic and social unrest. The answers are not easy or clear, but our health care system and our nation have faced much greater challenges. The 1918 flu pandemic was much more devastating, killing millions worldwide, and recall, 620,000 died in the Civil War, more than all other American wars combined. There is a deep seam of grit and resilience in Americans. We don’t always get it right immediately, but we usually do in the end.

The protests are justifiable outrage over police brutality, fueled by a high unemployment rate, both of which are a cause for frustration. The looting and destruction appears to be opportunistic thievery and some organized vandalization in my opinion. Most of the damage caused by riots and looting is not covered by insurance, and this will be a death blow to many small businesses already facing major financial setbacks as customers have stayed home for months and laying off staff has become necessary.

As for the impact on our practices, most physicians have been lucky and not been looted or burned out. Most of us have resumed practice, at least in a limited fashion, wearing masks; keeping the waiting room mostly empty; using social distancing and hand, air, and surface disinfection. In most of the country, the disease incidence has become lower, and the risk of not seeing the doctor is now greater than catching COVID-19.

So show grit, be careful, be vigilant, and practice your profession. Support your local small businesses, particularly if they have been the victims of senseless violence. We will work our way through these times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He had no disclosures related to this column. Write to him at [email protected].

Grandma Exie used to tell a story about her grandmother on her father’s side, who lived in northeastern Arkansas. Towards the end of the Civil War, Northern and Southern troops were expected to “live off the land,” and both sides had torn through her poor dirt farm and carried off all the livestock and crops. The only thing they didn’t take was her bull mastiff, who was a pretty fair hunting and guard dog. Starving, she had no other option than to pack up and head east for Tennessee, where her husband was stationed with Joseph Hooker’s army. Many thousands of destitute women and children, most of whom were related to one of the troops, followed the army, where some of the army’s rations could be shared with them.

She headed out on foot and all went well until day 3 or so, when a panther attacked them, but she, armed with a branch, and her loyal dog were able to drive it off. The panther followed them for 3 days while she hid in a tree at night with her dog at the foot of a tree. Eventually, the panther gave up and she made it to Tennessee to safety.

Grandma Exie said her grandmother had “grit” and used this story whenever any of us would complain about how hard times were or how we were mistreated.

It is time for all of us to buck up and show a little grit in the face of a viral pandemic and social unrest. The answers are not easy or clear, but our health care system and our nation have faced much greater challenges. The 1918 flu pandemic was much more devastating, killing millions worldwide, and recall, 620,000 died in the Civil War, more than all other American wars combined. There is a deep seam of grit and resilience in Americans. We don’t always get it right immediately, but we usually do in the end.

The protests are justifiable outrage over police brutality, fueled by a high unemployment rate, both of which are a cause for frustration. The looting and destruction appears to be opportunistic thievery and some organized vandalization in my opinion. Most of the damage caused by riots and looting is not covered by insurance, and this will be a death blow to many small businesses already facing major financial setbacks as customers have stayed home for months and laying off staff has become necessary.

As for the impact on our practices, most physicians have been lucky and not been looted or burned out. Most of us have resumed practice, at least in a limited fashion, wearing masks; keeping the waiting room mostly empty; using social distancing and hand, air, and surface disinfection. In most of the country, the disease incidence has become lower, and the risk of not seeing the doctor is now greater than catching COVID-19.

So show grit, be careful, be vigilant, and practice your profession. Support your local small businesses, particularly if they have been the victims of senseless violence. We will work our way through these times.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He had no disclosures related to this column. Write to him at [email protected].

The slow-moving game of viral roulette is wearing on everyone. Eventually, we may all become fatigued and say, “well, let’s just take our chances,” the isolation being worse than the disease. I must say, however, the sight of the local funeral director loading lumber into his van at the hardware store last week made me snug up my mask a bit. We have had a surge of COVID-19 deaths in local nursing homes and I heard refrigerated space is tight. Who knows, though, maybe he just needed more shelf space in his garage.

The most exasperating thing is not knowing who has had the virus and who hasn’t, and what medicine might or might not work. My son, quartered in the sardine-tin bunks of an aircraft carrier has “it,” as do all his mates, is in total isolation except for fever checks once a day, and is having a tough time. His eagerness to receive our phone calls was sweet at first, but is now starting to worry me. Today, I received a letter from him, which I dutifully steam-microwaved for 5 minutes and am letting dry in the sun. He is asymptomatic by the way. This was not the case for one of my buddies in New York. He suffered through 10 days of shaking chills so bad he thought he had chipped his teeth, and weeks later he still has no sense of smell.

My practice has been completely disrupted, but we are open a couple of days a week. I have kept all my employees, doing busy things mostly. There will be long hours for everyone because of widely spaced appointments and a certain amount of friction with patients who miss appointments. My fellow is going to take a long trip in July. Who knows when he will have a month off again? I wonder where he plans to go.

We have rearranged the waiting room furniture, so everyone is 6 feet apart, though I am not confident this makes a difference. We all have masks, and use alcohol gel before and after patient encounters, and spritz all fixtures and handles with alcohol after encounters. I have a large exhaust fan in the lab that creates a negative pressure gradient in the office. Somehow, I don’t think it is quite the same as in the hospital.

One slick trick we’ve enacted is running an ozone generator in the office at night, which will kill all things on all surfaces and in the air. It also is probably eroding the insides of my computers, but hey, the insects and burglars hate it too.

We heard the fighter jets fly over today saluting the frontline health care workers, but did not go out and wave. We are taking care of skin cancers, and while my patients might have COVID, they do not have a fever or cough, and are not supposed to come in if they do. I feel a little guilt about this. Treating cancer is important, but we are not in the ICU or ED immersed in virus. That is who the jets are for.

My daughter, a high school senior, is taking the loss of graduation, prom, and pomp and circumstance quite well. I am relieved I don’t have to worry about the after-prom parties. She is gearing up for college, I just hope they allow classes to start.

The future is cloudy and uncertain, despite this beautiful spring day as I write this column. Surely the way we practice medicine is going to change, and for a long while. I am thinking of taking a part-time job out of town for a year or so, and my wife is considering closing her practice altogether. If we were a few years older, there is little doubt we would just move it down the line and retire.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He has no disclosures. Write to him at [email protected].

The slow-moving game of viral roulette is wearing on everyone. Eventually, we may all become fatigued and say, “well, let’s just take our chances,” the isolation being worse than the disease. I must say, however, the sight of the local funeral director loading lumber into his van at the hardware store last week made me snug up my mask a bit. We have had a surge of COVID-19 deaths in local nursing homes and I heard refrigerated space is tight. Who knows, though, maybe he just needed more shelf space in his garage.

The most exasperating thing is not knowing who has had the virus and who hasn’t, and what medicine might or might not work. My son, quartered in the sardine-tin bunks of an aircraft carrier has “it,” as do all his mates, is in total isolation except for fever checks once a day, and is having a tough time. His eagerness to receive our phone calls was sweet at first, but is now starting to worry me. Today, I received a letter from him, which I dutifully steam-microwaved for 5 minutes and am letting dry in the sun. He is asymptomatic by the way. This was not the case for one of my buddies in New York. He suffered through 10 days of shaking chills so bad he thought he had chipped his teeth, and weeks later he still has no sense of smell.

My practice has been completely disrupted, but we are open a couple of days a week. I have kept all my employees, doing busy things mostly. There will be long hours for everyone because of widely spaced appointments and a certain amount of friction with patients who miss appointments. My fellow is going to take a long trip in July. Who knows when he will have a month off again? I wonder where he plans to go.

We have rearranged the waiting room furniture, so everyone is 6 feet apart, though I am not confident this makes a difference. We all have masks, and use alcohol gel before and after patient encounters, and spritz all fixtures and handles with alcohol after encounters. I have a large exhaust fan in the lab that creates a negative pressure gradient in the office. Somehow, I don’t think it is quite the same as in the hospital.

One slick trick we’ve enacted is running an ozone generator in the office at night, which will kill all things on all surfaces and in the air. It also is probably eroding the insides of my computers, but hey, the insects and burglars hate it too.

We heard the fighter jets fly over today saluting the frontline health care workers, but did not go out and wave. We are taking care of skin cancers, and while my patients might have COVID, they do not have a fever or cough, and are not supposed to come in if they do. I feel a little guilt about this. Treating cancer is important, but we are not in the ICU or ED immersed in virus. That is who the jets are for.

My daughter, a high school senior, is taking the loss of graduation, prom, and pomp and circumstance quite well. I am relieved I don’t have to worry about the after-prom parties. She is gearing up for college, I just hope they allow classes to start.

The future is cloudy and uncertain, despite this beautiful spring day as I write this column. Surely the way we practice medicine is going to change, and for a long while. I am thinking of taking a part-time job out of town for a year or so, and my wife is considering closing her practice altogether. If we were a few years older, there is little doubt we would just move it down the line and retire.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He has no disclosures. Write to him at [email protected].

The slow-moving game of viral roulette is wearing on everyone. Eventually, we may all become fatigued and say, “well, let’s just take our chances,” the isolation being worse than the disease. I must say, however, the sight of the local funeral director loading lumber into his van at the hardware store last week made me snug up my mask a bit. We have had a surge of COVID-19 deaths in local nursing homes and I heard refrigerated space is tight. Who knows, though, maybe he just needed more shelf space in his garage.

The most exasperating thing is not knowing who has had the virus and who hasn’t, and what medicine might or might not work. My son, quartered in the sardine-tin bunks of an aircraft carrier has “it,” as do all his mates, is in total isolation except for fever checks once a day, and is having a tough time. His eagerness to receive our phone calls was sweet at first, but is now starting to worry me. Today, I received a letter from him, which I dutifully steam-microwaved for 5 minutes and am letting dry in the sun. He is asymptomatic by the way. This was not the case for one of my buddies in New York. He suffered through 10 days of shaking chills so bad he thought he had chipped his teeth, and weeks later he still has no sense of smell.

My practice has been completely disrupted, but we are open a couple of days a week. I have kept all my employees, doing busy things mostly. There will be long hours for everyone because of widely spaced appointments and a certain amount of friction with patients who miss appointments. My fellow is going to take a long trip in July. Who knows when he will have a month off again? I wonder where he plans to go.

We have rearranged the waiting room furniture, so everyone is 6 feet apart, though I am not confident this makes a difference. We all have masks, and use alcohol gel before and after patient encounters, and spritz all fixtures and handles with alcohol after encounters. I have a large exhaust fan in the lab that creates a negative pressure gradient in the office. Somehow, I don’t think it is quite the same as in the hospital.

One slick trick we’ve enacted is running an ozone generator in the office at night, which will kill all things on all surfaces and in the air. It also is probably eroding the insides of my computers, but hey, the insects and burglars hate it too.

We heard the fighter jets fly over today saluting the frontline health care workers, but did not go out and wave. We are taking care of skin cancers, and while my patients might have COVID, they do not have a fever or cough, and are not supposed to come in if they do. I feel a little guilt about this. Treating cancer is important, but we are not in the ICU or ED immersed in virus. That is who the jets are for.

My daughter, a high school senior, is taking the loss of graduation, prom, and pomp and circumstance quite well. I am relieved I don’t have to worry about the after-prom parties. She is gearing up for college, I just hope they allow classes to start.

The future is cloudy and uncertain, despite this beautiful spring day as I write this column. Surely the way we practice medicine is going to change, and for a long while. I am thinking of taking a part-time job out of town for a year or so, and my wife is considering closing her practice altogether. If we were a few years older, there is little doubt we would just move it down the line and retire.

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. He has no disclosures. Write to him at [email protected].

The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.

Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).

Now, let’s consider the more mundane issue of keeping your medical practice alive.

Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.

But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?

Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.

But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).

The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.

Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.

Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.

This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?

It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.


 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]. He has no disclosures.

The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.

Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).

Now, let’s consider the more mundane issue of keeping your medical practice alive.

Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.

But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?

Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.

But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).

The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.

Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.

Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.

This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?

It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.


 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]. He has no disclosures.

The last few weeks have been confusing and a little overwhelming. A hodgepodge of rapid-fire publications of potential treatments and multiple, sometimes confusing government mandates and initiatives have inundated us. The overriding theme is clear, though: Let’s first concentrate on keeping our civilization intact. State governments have been largely focused on “flattening the curve” of new infections. And the longer we slow this disease down, the better we learn how to treat it.

Multiple existing medications, repurposed from all walks of the pharmacologic world, have been screened and shown to have potential therapeutic benefit, and they are being tested even as I write this column. The nasty form of this disease is a unique form of adult respiratory distress syndrome, and the terminal event appears to be a form of disseminated intravascular coagulation, which may respond to unexpected therapies, such as clot busters (J Thromb Haemost. 2020 Apr 8. doi: 10.1111/jth.14828).

Now, let’s consider the more mundane issue of keeping your medical practice alive.

Some state medical boards have relaxed the rules on licensing, and the federal government on HIPAA compliance, so that telemedicine has finally become practical. Some EHR vendors have even rushed out modules to make it easier to conduct visits with patients through their patient portals. This has all made it almost practical to see, monitor, and treat existing patients with chronic conditions, and even new ones who do not require a biopsy.

But it has also become clear that telemedicine is not a long-term means of keeping your practice viable, at least not in your practice’s current form. It can be difficult to enroll new patients and the process of collecting copays and deductibles can be frustrating and slow. There may also resistance from our patients, who may be used to having this sort of service performed by us free-of-charge. Those selfies that in the past you may have viewed, called the patient to discuss, and then called their medication into the pharmacy – all as a convenience – are coming back to haunt you. It was free before, they say, what has changed?

Another obstacle, as always, is reimbursement. There is an inconsistent patchwork of private insurance coverage that may or may not pay you. The American Academy of Dermatology has put together an excellent resource on its web site on all matters regarding COVID-19 to help you.

But the underlying undeniable reality is that you cannot support your current practice model long term with telemedicine because only about 30% of dermatology reimbursement comes from evaluation and management codes, according to a recently published study – and the rest, procedures, obviously requires patient contact (JAMA Surg. 2020 Apr 15. doi: 10.1001/jamasurg.2020.0422).

The federal government has been economically responsive by injecting money into businesses with less than 500 employees. Most of you will be eligible and probably already have applied for the Paycheck Protection Program. These are small business “loans” that your bank puts the paperwork in for, which can total up to 2.5 times one month’s average payroll. These “loans” may be 100% forgivable (75% must come from two months payroll, another 25% rent and expenses) if you do not lay anyone off.

Employees can be kept busy doing other tasks besides directly helping with patients. Like many of you with state-mandated lockdowns, my office has never been so clean, the cabinets so well stocked, and the files so organized. The stock room has been cleaned out, and any extra personal protective gear has been donated to the hospital and emergency medical services. We have landscaped the front of our building and if it warms up, we will seal and remark the parking lot. You get my drift. I have also applied for and received an advance of three months of Medicare payments, which will be automatically paid back as practice resumes. This is in effect an interest-free loan. A few days ago, my business checking account received a deposit from the Department of Health & Human Services for 6.1% of last year’s Medicare billings. This is unexpected, no obligation support to help keep your medical office open in the time of COVID-19. It appears that the office and practice will be able to weather the fire.

Assuming our practices survive more or less intact, there are major social consequences to consider. Society is a conglomeration of individuals, and individuals act on their Maslow’s hierarchy of needs (a concept introduced by psychologist Abraham Maslow, PhD, over 75 years ago). Our society has already slid down several of Maslow’s levels. We have reset to about level two, which is safety, one level above physiologic needs. Recall the grocery store fights. Look at the gun sales. The toilet paper roll has been reset from wheel of fortune spin to safe cracking mode.

This reset of the societal mindset has many ramifications you may not normally consider. For example, who will risk buying up to that dream home or purchasing a second home, if you are being told to shelter in place? Fewer may gamble $300,000 on a college education at a less-than-top-50 school. Who even knows when college will start next year. Who is going to take that promotion to New York City, or even New Jersey, and ride the train and subway to work every day? Who wants to commute through the crowded airport on the jam packed “plane train”?

It is easy to predict we will see a severe recession followed by higher taxes and inflation (stagflation). There is a financial writer I like to read who has been predicting a “great reset” of American society for several years. COVID-19 may have precipitated that reset, and things may never be the same.


 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected]. He has no disclosures.

My apricot tree has bloomed. It is a foolish tree planted by a foolish man since it blossoms, with beautiful pink then white flowers, at least 3 weeks too early in Northern Kentucky. Nonetheless, I am hopeful that it will produce fruit, maybe this year.

The apricot tree takes me back to my early childhood in Oklahoma City. We had a small apricot tree in the backyard of our rental house, and my dad would talk about how there was nothing finer than a sun ripened apricot. Those were happy times. My dad was a milkman and was home every day by late afternoon, though he was still taking classes at night to try to finish his degree. My mother was at home and my older brother in first grade down the street. My little sister was small and tried to keep up.

My time was unstructured, and I reveled in the backyard. In retrospect, the backyard was an open display of broken and hoped for dreams. There was a junked car my best friend Alvin and I would sit in, there was a huge tree stump we sat on and played around, we had an old slow dog named Pooch, gifted to us when my mom’s sister moved to Alaska. We ran around with no shirts or shoes, played and pretended, and carefully watched the apricot tree.

I remember one time when the apricots finally ripened. My father climbed up and got me one, and it was so sweet I did not notice that the juice ran down my face and my bare chest. It was the sweetest and most wonderful thing I have ever tasted. All the better for having to wait for it.

The current pandemic has once again made my life unstructured, with a lot of free time to think. I have had four major meetings canceled and though my livelihood and life are at risk, I feel oddly free and happy. I am no longer under those pressures to research, write, and present, and am spending at lot of time at home with my wife and daughter. I think I will clean out the garage (who knows what I will find?) and work in the backyard – and keep a close watch on the apricot tree.

As many of you have, I have awkwardly embraced telemedicine in the past. It is interesting now, how HIPAA regulations and state licensing requirements have finally been tossed aside, making it possible to practice telemedicine. I suspect things will stay that way if it is demonstrated they are unnecessary.

In my office, we are depopulating the waiting room and autoclaving face masks. I am cleaning out the stockroom and donating extra gloves, gowns, and masks to the local hospital. We may shut down altogether. There is little more I can do unless called to man a ventilator. I hope it doesn’t come to that, but I will serve if called.

I suggest you embrace your current unstructured time and use it to let your mind roam. It is a reprieve from today’s hyperconnected, hurly burly world. I also suggest you check COVID-19 news updates only once a day and turn off television news altogether. Other than following the recommendations and guidance of public health authorities, there is nothing you can do to speed up the resolution of this pandemic.

No matter how awful, this will pass. It is a warm spring and it is possible the apricot tree will not be bitten by frost, and we may have fruit this year. We should know in about 2 months. I am going to keep a close watch on it.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My apricot tree has bloomed. It is a foolish tree planted by a foolish man since it blossoms, with beautiful pink then white flowers, at least 3 weeks too early in Northern Kentucky. Nonetheless, I am hopeful that it will produce fruit, maybe this year.

The apricot tree takes me back to my early childhood in Oklahoma City. We had a small apricot tree in the backyard of our rental house, and my dad would talk about how there was nothing finer than a sun ripened apricot. Those were happy times. My dad was a milkman and was home every day by late afternoon, though he was still taking classes at night to try to finish his degree. My mother was at home and my older brother in first grade down the street. My little sister was small and tried to keep up.

My time was unstructured, and I reveled in the backyard. In retrospect, the backyard was an open display of broken and hoped for dreams. There was a junked car my best friend Alvin and I would sit in, there was a huge tree stump we sat on and played around, we had an old slow dog named Pooch, gifted to us when my mom’s sister moved to Alaska. We ran around with no shirts or shoes, played and pretended, and carefully watched the apricot tree.

I remember one time when the apricots finally ripened. My father climbed up and got me one, and it was so sweet I did not notice that the juice ran down my face and my bare chest. It was the sweetest and most wonderful thing I have ever tasted. All the better for having to wait for it.

The current pandemic has once again made my life unstructured, with a lot of free time to think. I have had four major meetings canceled and though my livelihood and life are at risk, I feel oddly free and happy. I am no longer under those pressures to research, write, and present, and am spending at lot of time at home with my wife and daughter. I think I will clean out the garage (who knows what I will find?) and work in the backyard – and keep a close watch on the apricot tree.

As many of you have, I have awkwardly embraced telemedicine in the past. It is interesting now, how HIPAA regulations and state licensing requirements have finally been tossed aside, making it possible to practice telemedicine. I suspect things will stay that way if it is demonstrated they are unnecessary.

In my office, we are depopulating the waiting room and autoclaving face masks. I am cleaning out the stockroom and donating extra gloves, gowns, and masks to the local hospital. We may shut down altogether. There is little more I can do unless called to man a ventilator. I hope it doesn’t come to that, but I will serve if called.

I suggest you embrace your current unstructured time and use it to let your mind roam. It is a reprieve from today’s hyperconnected, hurly burly world. I also suggest you check COVID-19 news updates only once a day and turn off television news altogether. Other than following the recommendations and guidance of public health authorities, there is nothing you can do to speed up the resolution of this pandemic.

No matter how awful, this will pass. It is a warm spring and it is possible the apricot tree will not be bitten by frost, and we may have fruit this year. We should know in about 2 months. I am going to keep a close watch on it.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My apricot tree has bloomed. It is a foolish tree planted by a foolish man since it blossoms, with beautiful pink then white flowers, at least 3 weeks too early in Northern Kentucky. Nonetheless, I am hopeful that it will produce fruit, maybe this year.

The apricot tree takes me back to my early childhood in Oklahoma City. We had a small apricot tree in the backyard of our rental house, and my dad would talk about how there was nothing finer than a sun ripened apricot. Those were happy times. My dad was a milkman and was home every day by late afternoon, though he was still taking classes at night to try to finish his degree. My mother was at home and my older brother in first grade down the street. My little sister was small and tried to keep up.

My time was unstructured, and I reveled in the backyard. In retrospect, the backyard was an open display of broken and hoped for dreams. There was a junked car my best friend Alvin and I would sit in, there was a huge tree stump we sat on and played around, we had an old slow dog named Pooch, gifted to us when my mom’s sister moved to Alaska. We ran around with no shirts or shoes, played and pretended, and carefully watched the apricot tree.

I remember one time when the apricots finally ripened. My father climbed up and got me one, and it was so sweet I did not notice that the juice ran down my face and my bare chest. It was the sweetest and most wonderful thing I have ever tasted. All the better for having to wait for it.

The current pandemic has once again made my life unstructured, with a lot of free time to think. I have had four major meetings canceled and though my livelihood and life are at risk, I feel oddly free and happy. I am no longer under those pressures to research, write, and present, and am spending at lot of time at home with my wife and daughter. I think I will clean out the garage (who knows what I will find?) and work in the backyard – and keep a close watch on the apricot tree.

As many of you have, I have awkwardly embraced telemedicine in the past. It is interesting now, how HIPAA regulations and state licensing requirements have finally been tossed aside, making it possible to practice telemedicine. I suspect things will stay that way if it is demonstrated they are unnecessary.

In my office, we are depopulating the waiting room and autoclaving face masks. I am cleaning out the stockroom and donating extra gloves, gowns, and masks to the local hospital. We may shut down altogether. There is little more I can do unless called to man a ventilator. I hope it doesn’t come to that, but I will serve if called.

I suggest you embrace your current unstructured time and use it to let your mind roam. It is a reprieve from today’s hyperconnected, hurly burly world. I also suggest you check COVID-19 news updates only once a day and turn off television news altogether. Other than following the recommendations and guidance of public health authorities, there is nothing you can do to speed up the resolution of this pandemic.

No matter how awful, this will pass. It is a warm spring and it is possible the apricot tree will not be bitten by frost, and we may have fruit this year. We should know in about 2 months. I am going to keep a close watch on it.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My wife thinks I am a little morbid, because I still read the local Sunday newspaper not to catch up on the news, and certainly not for the ads, but mostly to read the obituaries.

All of us have elderly patients, and I am growing old with many of my older patients. Now after treating many thousands of patients whom I have grown to know well, it is not unusual to see an obituary of someone my office staff and I know in the newspaper on a weekly basis.

We send sympathy cards, sometimes I write a personal note to the spouse or family, and several times a year, some of my staff and I will go to the funeral or memorial ceremony.

I usually ask if they died well, comfortably with family, or better yet, suddenly, dropping dead like a stone. This is the unspoken, though usually unrealized, goal of many of us from the world of medicine.

All physicians who have been surrounded by death, some horrible deaths, want to die well. I think it is difficult to do, although my mother came close.

One day when dropping off her best little friend (my 10-year-old daughter), she said “look here, I’ve got a knot in my belly button.” I felt the blood rushing to my head and before I could stop her, she showed me her Sister Mary Joseph nodule, a sign of metastatic internal malignancy. I sat stunned as she looked at me; her eyes showed she already knew my answer.

She lasted at home for 6 weeks, went into hospice, and died 36 hours later.

The last morning before she died, I took my daughter to see her before school. She woke up and called her “sugar” and had her climb into bed with her and snuggle. I got choked up and tearful and started telling her how much I loved her and how sorry I was and how much we would miss her. She looked over at me, and with anger in her voice, told me to be quiet, and explained that death comes to everyone eventually and just to get over it. In retrospect, I understand now that I was not helping her die well.

I am telling this story to bring up a point about professionalism. A crucial part of professionalism is a responsiveness to patients’ needs that supersedes self interest. As dermatologists who treat skin cancer, this becomes important as the life cycle ends. Aged patients sometimes start blossoming with skin cancers. You must carefully gauge how much “treatment” a patient really needs.

You have a conflict. You get paid to diagnose and treat skin cancers. You must shift roles and become the patient’s protector, and treat the patient as if he or she was your parent. Less, sometimes much less, is often more. Perhaps you only biopsy and treat rapidly growing cancers that endanger crucial structures. You ignore the noninvasive tumors on the trunk and extremities. It is a fine and difficult line to walk.

Patients know they are dying, and at certain stages of grieving will want everything possible done, especially if it is visible. Skin wounds, even from curetting, salves, and cryotherapy, can be painful and sometimes disabling. You must resist unnecessary treatments, temporize if possible, discuss quality time with the patient and the family, and reach a consensus on how aggressive not to be. You must help them die well.

You are not only a healer, but as a master physician you – yes, even you the dermatologist – must also be a helpful guide at the end of life. I am sad to see patients, my old friends, in the newspaper, but feel secretly satisfied if I have spared them unnecessary suffering.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My wife thinks I am a little morbid, because I still read the local Sunday newspaper not to catch up on the news, and certainly not for the ads, but mostly to read the obituaries.

All of us have elderly patients, and I am growing old with many of my older patients. Now after treating many thousands of patients whom I have grown to know well, it is not unusual to see an obituary of someone my office staff and I know in the newspaper on a weekly basis.

We send sympathy cards, sometimes I write a personal note to the spouse or family, and several times a year, some of my staff and I will go to the funeral or memorial ceremony.

I usually ask if they died well, comfortably with family, or better yet, suddenly, dropping dead like a stone. This is the unspoken, though usually unrealized, goal of many of us from the world of medicine.

All physicians who have been surrounded by death, some horrible deaths, want to die well. I think it is difficult to do, although my mother came close.

One day when dropping off her best little friend (my 10-year-old daughter), she said “look here, I’ve got a knot in my belly button.” I felt the blood rushing to my head and before I could stop her, she showed me her Sister Mary Joseph nodule, a sign of metastatic internal malignancy. I sat stunned as she looked at me; her eyes showed she already knew my answer.

She lasted at home for 6 weeks, went into hospice, and died 36 hours later.

The last morning before she died, I took my daughter to see her before school. She woke up and called her “sugar” and had her climb into bed with her and snuggle. I got choked up and tearful and started telling her how much I loved her and how sorry I was and how much we would miss her. She looked over at me, and with anger in her voice, told me to be quiet, and explained that death comes to everyone eventually and just to get over it. In retrospect, I understand now that I was not helping her die well.

I am telling this story to bring up a point about professionalism. A crucial part of professionalism is a responsiveness to patients’ needs that supersedes self interest. As dermatologists who treat skin cancer, this becomes important as the life cycle ends. Aged patients sometimes start blossoming with skin cancers. You must carefully gauge how much “treatment” a patient really needs.

You have a conflict. You get paid to diagnose and treat skin cancers. You must shift roles and become the patient’s protector, and treat the patient as if he or she was your parent. Less, sometimes much less, is often more. Perhaps you only biopsy and treat rapidly growing cancers that endanger crucial structures. You ignore the noninvasive tumors on the trunk and extremities. It is a fine and difficult line to walk.

Patients know they are dying, and at certain stages of grieving will want everything possible done, especially if it is visible. Skin wounds, even from curetting, salves, and cryotherapy, can be painful and sometimes disabling. You must resist unnecessary treatments, temporize if possible, discuss quality time with the patient and the family, and reach a consensus on how aggressive not to be. You must help them die well.

You are not only a healer, but as a master physician you – yes, even you the dermatologist – must also be a helpful guide at the end of life. I am sad to see patients, my old friends, in the newspaper, but feel secretly satisfied if I have spared them unnecessary suffering.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

My wife thinks I am a little morbid, because I still read the local Sunday newspaper not to catch up on the news, and certainly not for the ads, but mostly to read the obituaries.

All of us have elderly patients, and I am growing old with many of my older patients. Now after treating many thousands of patients whom I have grown to know well, it is not unusual to see an obituary of someone my office staff and I know in the newspaper on a weekly basis.

We send sympathy cards, sometimes I write a personal note to the spouse or family, and several times a year, some of my staff and I will go to the funeral or memorial ceremony.

I usually ask if they died well, comfortably with family, or better yet, suddenly, dropping dead like a stone. This is the unspoken, though usually unrealized, goal of many of us from the world of medicine.

All physicians who have been surrounded by death, some horrible deaths, want to die well. I think it is difficult to do, although my mother came close.

One day when dropping off her best little friend (my 10-year-old daughter), she said “look here, I’ve got a knot in my belly button.” I felt the blood rushing to my head and before I could stop her, she showed me her Sister Mary Joseph nodule, a sign of metastatic internal malignancy. I sat stunned as she looked at me; her eyes showed she already knew my answer.

She lasted at home for 6 weeks, went into hospice, and died 36 hours later.

The last morning before she died, I took my daughter to see her before school. She woke up and called her “sugar” and had her climb into bed with her and snuggle. I got choked up and tearful and started telling her how much I loved her and how sorry I was and how much we would miss her. She looked over at me, and with anger in her voice, told me to be quiet, and explained that death comes to everyone eventually and just to get over it. In retrospect, I understand now that I was not helping her die well.

I am telling this story to bring up a point about professionalism. A crucial part of professionalism is a responsiveness to patients’ needs that supersedes self interest. As dermatologists who treat skin cancer, this becomes important as the life cycle ends. Aged patients sometimes start blossoming with skin cancers. You must carefully gauge how much “treatment” a patient really needs.

You have a conflict. You get paid to diagnose and treat skin cancers. You must shift roles and become the patient’s protector, and treat the patient as if he or she was your parent. Less, sometimes much less, is often more. Perhaps you only biopsy and treat rapidly growing cancers that endanger crucial structures. You ignore the noninvasive tumors on the trunk and extremities. It is a fine and difficult line to walk.

Patients know they are dying, and at certain stages of grieving will want everything possible done, especially if it is visible. Skin wounds, even from curetting, salves, and cryotherapy, can be painful and sometimes disabling. You must resist unnecessary treatments, temporize if possible, discuss quality time with the patient and the family, and reach a consensus on how aggressive not to be. You must help them die well.

You are not only a healer, but as a master physician you – yes, even you the dermatologist – must also be a helpful guide at the end of life. I am sad to see patients, my old friends, in the newspaper, but feel secretly satisfied if I have spared them unnecessary suffering.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

It’s almost a New Year and a good time to look back and reflect on the past year. Here are seven things I am grateful for.

The wildlife in my backyard provides endless entertainment. Not only the birds, rabbits, squirrels, raccoons, and skunks, but turkey, red fox, coyote, hawk, and even a mink. At some point, I quit buying koi for the pond and substituted dime gold fish. Of course, we cannot overlook the deer, who trash my shrubs, eat and grind the bark off my baby trees, consume my garden (don’t they know tomato plants are related to deadly nightshade?), and shed ticks. They watch me with calm indifference, even when I shout at them.

Most folks hate cold weather, but it kills the mosquitoes and stink bugs, and allows me to build mesmerizing fires. It is time to clean the yard, turn over the garden, plant new things, all without breaking much of a sweat. It is almost time to empty the compost pile onto the garden mixed with the ashes from the fire pit.

Last year’s tomato crop started late but was a blockbuster. I plant heirlooms grafted onto resistant rootstock (territorial seed company) placed under walls of water in April. I cage them up high. I like to stand in the tomato jungle in high summer, invisible for a few minutes, and eat the little cherry tomatoes and think about nothing but how perfectly the sweetness and tartness is balanced. I still have a few on the kitchen counter making that crucial, very late, decision on whether to ripen or rot.

The U.S. Navy cannot be thanked enough for taking my defiant teenage boy and molding him into what is starting to resemble a fine young man. The Navy is what he needed.

I give much professional credit to my office staff and my patients. I really haven’t run the office for years; it has its own rhythm and knowledge. You spend more waking hours there than at home, so being fun and entertaining is important. That said, the hiring and management of employees is the most difficult part of running a small office. The patients generally know to come in sooner rather than later if they start growing something ugly. And I have also been blessed with good health, mandatory for maintaining a small office. It’s been a good ride.

My wife is quiet when I am loud, reserved when I am bombastic, an only child matched with a middle. She wears a child’s size bicycle helmet, but her head is packed with brains. She knows millions of things I don’t. She is terribly organized. I float my crazy ideas past her daily and leave with punctured remnants to patch together into a better weave. We spend all our free time together, which is the way it ought to be.

Finally, of course, I am grateful for my specialty of dermatology. I kind of wandered into dermatology after internal medicine, and after seriously considering cardiology. It is a happy and joyous specialty with enough cures and successes to keep gloom and hopelessness at bay. I look forward to going to work and get great satisfaction from my work. I have continued to improve in this field, which gives so much more than it takes.

So enjoy the New Year! Take time to build a roaring fire, buy quirky gifts for your staff, get your spouses or significant others whatever they want, and enjoy your specialty as a dermatologist. You are in one of the best places in the world.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

It’s almost a New Year and a good time to look back and reflect on the past year. Here are seven things I am grateful for.

The wildlife in my backyard provides endless entertainment. Not only the birds, rabbits, squirrels, raccoons, and skunks, but turkey, red fox, coyote, hawk, and even a mink. At some point, I quit buying koi for the pond and substituted dime gold fish. Of course, we cannot overlook the deer, who trash my shrubs, eat and grind the bark off my baby trees, consume my garden (don’t they know tomato plants are related to deadly nightshade?), and shed ticks. They watch me with calm indifference, even when I shout at them.

Most folks hate cold weather, but it kills the mosquitoes and stink bugs, and allows me to build mesmerizing fires. It is time to clean the yard, turn over the garden, plant new things, all without breaking much of a sweat. It is almost time to empty the compost pile onto the garden mixed with the ashes from the fire pit.

Last year’s tomato crop started late but was a blockbuster. I plant heirlooms grafted onto resistant rootstock (territorial seed company) placed under walls of water in April. I cage them up high. I like to stand in the tomato jungle in high summer, invisible for a few minutes, and eat the little cherry tomatoes and think about nothing but how perfectly the sweetness and tartness is balanced. I still have a few on the kitchen counter making that crucial, very late, decision on whether to ripen or rot.

The U.S. Navy cannot be thanked enough for taking my defiant teenage boy and molding him into what is starting to resemble a fine young man. The Navy is what he needed.

I give much professional credit to my office staff and my patients. I really haven’t run the office for years; it has its own rhythm and knowledge. You spend more waking hours there than at home, so being fun and entertaining is important. That said, the hiring and management of employees is the most difficult part of running a small office. The patients generally know to come in sooner rather than later if they start growing something ugly. And I have also been blessed with good health, mandatory for maintaining a small office. It’s been a good ride.

My wife is quiet when I am loud, reserved when I am bombastic, an only child matched with a middle. She wears a child’s size bicycle helmet, but her head is packed with brains. She knows millions of things I don’t. She is terribly organized. I float my crazy ideas past her daily and leave with punctured remnants to patch together into a better weave. We spend all our free time together, which is the way it ought to be.

Finally, of course, I am grateful for my specialty of dermatology. I kind of wandered into dermatology after internal medicine, and after seriously considering cardiology. It is a happy and joyous specialty with enough cures and successes to keep gloom and hopelessness at bay. I look forward to going to work and get great satisfaction from my work. I have continued to improve in this field, which gives so much more than it takes.

So enjoy the New Year! Take time to build a roaring fire, buy quirky gifts for your staff, get your spouses or significant others whatever they want, and enjoy your specialty as a dermatologist. You are in one of the best places in the world.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

It’s almost a New Year and a good time to look back and reflect on the past year. Here are seven things I am grateful for.

The wildlife in my backyard provides endless entertainment. Not only the birds, rabbits, squirrels, raccoons, and skunks, but turkey, red fox, coyote, hawk, and even a mink. At some point, I quit buying koi for the pond and substituted dime gold fish. Of course, we cannot overlook the deer, who trash my shrubs, eat and grind the bark off my baby trees, consume my garden (don’t they know tomato plants are related to deadly nightshade?), and shed ticks. They watch me with calm indifference, even when I shout at them.

Most folks hate cold weather, but it kills the mosquitoes and stink bugs, and allows me to build mesmerizing fires. It is time to clean the yard, turn over the garden, plant new things, all without breaking much of a sweat. It is almost time to empty the compost pile onto the garden mixed with the ashes from the fire pit.

Last year’s tomato crop started late but was a blockbuster. I plant heirlooms grafted onto resistant rootstock (territorial seed company) placed under walls of water in April. I cage them up high. I like to stand in the tomato jungle in high summer, invisible for a few minutes, and eat the little cherry tomatoes and think about nothing but how perfectly the sweetness and tartness is balanced. I still have a few on the kitchen counter making that crucial, very late, decision on whether to ripen or rot.

The U.S. Navy cannot be thanked enough for taking my defiant teenage boy and molding him into what is starting to resemble a fine young man. The Navy is what he needed.

I give much professional credit to my office staff and my patients. I really haven’t run the office for years; it has its own rhythm and knowledge. You spend more waking hours there than at home, so being fun and entertaining is important. That said, the hiring and management of employees is the most difficult part of running a small office. The patients generally know to come in sooner rather than later if they start growing something ugly. And I have also been blessed with good health, mandatory for maintaining a small office. It’s been a good ride.

My wife is quiet when I am loud, reserved when I am bombastic, an only child matched with a middle. She wears a child’s size bicycle helmet, but her head is packed with brains. She knows millions of things I don’t. She is terribly organized. I float my crazy ideas past her daily and leave with punctured remnants to patch together into a better weave. We spend all our free time together, which is the way it ought to be.

Finally, of course, I am grateful for my specialty of dermatology. I kind of wandered into dermatology after internal medicine, and after seriously considering cardiology. It is a happy and joyous specialty with enough cures and successes to keep gloom and hopelessness at bay. I look forward to going to work and get great satisfaction from my work. I have continued to improve in this field, which gives so much more than it takes.

So enjoy the New Year! Take time to build a roaring fire, buy quirky gifts for your staff, get your spouses or significant others whatever they want, and enjoy your specialty as a dermatologist. You are in one of the best places in the world.
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I frequently get requests from residents and relocating dermatologists for information on finding the right job. There is some useful material pertaining to this topic on the American Academy of Dermatology website, which I helped develop. This should help you decide whether you want to go solo, small group, large group, VA, or academic practice. These options all have certain advantages and drawbacks.

Your first decision should be where you want to practice geographically, which will determine many of the details of any practice situation. For instance, if you go where there is a shortage of dermatologists, you will be more welcome and more sought after. I will never forget sitting in a hospital break room in New York City after giving grand rounds with a large group of residents, who asked me about practice opportunities. I asked them where they wanted to practice. Every resident – first, second, and third year – indicated they wanted to stay in New York City. I had to laugh to myself. If there are any cities with a surplus of dermatologists, it’s the hip ones: New York, San Francisco, Los Angeles, Miami, and so on. If you can find a job there, it will be a “this is what everyone signs” contract situation, and a large part of your pay is the privilege of living in an urban “paradise.”

If you are willing to look further afield, I suggest you start with an old classic, the “Places Rated Almanac: The Classic Guide for Finding Your Best Places to Live in America” (Washington: Places Rated Books, 2007). This is a resource (that needs a new edition) that provides all kinds of details on different areas of the country that you may not have considered, including median income, schools, climate, and livability.

When you know the general area where you would like to settle – and after considering the parents, the in-laws, and the outlaws – remember that the best jobs are not advertised. You should contact all the dermatology, multispeciality, and hospital groups in the area (yes, write them a nice snail mail letter) indicating you are interested, and ask them if they are hiring. Practices are usually interested in a general dermatologist, or perhaps a Mohs surgeon or dermatopathologist, willing to practice general dermatology half time. For example, I know a very nice general dermatology practice in the Midwest that has been looking for the right derm-path/general derm for years. The days of strolling in and setting up an all-Mohs or all-dermpath practice are over, unless you buy out, or become employed by one of the older established specialist groups.

Ask the staff (and former physician employees if you can find them) lots of questions. See if their style of medicine suits you. See if their electronic health record system is fast or a major hindrance. Find out how many extenders you will be responsible for supervising.

And find out if they are considering selling out (selling you) to private equity. Private equity groups are a major new influence on the specialty, run a lot of ads, and hire a lot of graduating dermatologists. They offer more benefits and higher initial salaries. There is no free lunch, however, and these perks must be paid back with future earnings. The private equity groups take 20%-30% of profits “off the top” and your earnings will hit a ceiling at a level that is significantly lower than it would be in a solo practice or dermatology group. They also have long, detailed, ferocious contracts with penalty clauses and noncompetes from all outlets. More numerous advertisements are a negative tip off, but will give you an idea of which markets they think are promising with regard to need and payer mix. See what the private equity group’s private health insurance rates are. If they are significantly greater than Medicare rates, they deserve a second look, though few are. Remember that the senior physician who pitches for them in the lounge doesn’t work for free, but receives a significant bonus for getting you to sign.

If you find a great location, it is time for contract review. The first rule is that no contract is better than who you sign it with. If they are determined to mistreat you, they will – no matter the contract. I advise always having a graceful exit written into the contract specifying severance terms (if any), even if you never need this.

If you are ready to work hard and make more income, you should forgo the perks and go on a percentage of collections basis. If you are considering a place where they very much need dermatologists (sorry, not New York City), you may have some negotiating room and it is worth spending a few thousand dollars to ask a medical contract attorney to go over the contract for you, or even negotiate for you. Don’t overestimate your value, however, because you might negotiate your way right out of a job. The expanding scope of nurse practitioners and physician assistants have taken away much of your indispensability. While there is a shortage of dermatologists in most of the United States, there generally is no shortage of dermatology appointments.

When you start a new job you are not certain about, resist the urge to buy a big house and put down roots right away. You may need to move on if it doesn’t work out. You may want to work a few years, pay down school loans, save a little, and set up your own practice somewhere.

All things considered, these are exciting times and being a board-certified dermatologist is a wonderful place to be in the medical world. I am not at all sure if any of the proposed end-of-the-world health care plans will come true. And let me know if you are one of those New York City residents who struck out for the western frontier. Us fly-over-country folk have got to stick together!
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I frequently get requests from residents and relocating dermatologists for information on finding the right job. There is some useful material pertaining to this topic on the American Academy of Dermatology website, which I helped develop. This should help you decide whether you want to go solo, small group, large group, VA, or academic practice. These options all have certain advantages and drawbacks.

Your first decision should be where you want to practice geographically, which will determine many of the details of any practice situation. For instance, if you go where there is a shortage of dermatologists, you will be more welcome and more sought after. I will never forget sitting in a hospital break room in New York City after giving grand rounds with a large group of residents, who asked me about practice opportunities. I asked them where they wanted to practice. Every resident – first, second, and third year – indicated they wanted to stay in New York City. I had to laugh to myself. If there are any cities with a surplus of dermatologists, it’s the hip ones: New York, San Francisco, Los Angeles, Miami, and so on. If you can find a job there, it will be a “this is what everyone signs” contract situation, and a large part of your pay is the privilege of living in an urban “paradise.”

If you are willing to look further afield, I suggest you start with an old classic, the “Places Rated Almanac: The Classic Guide for Finding Your Best Places to Live in America” (Washington: Places Rated Books, 2007). This is a resource (that needs a new edition) that provides all kinds of details on different areas of the country that you may not have considered, including median income, schools, climate, and livability.

When you know the general area where you would like to settle – and after considering the parents, the in-laws, and the outlaws – remember that the best jobs are not advertised. You should contact all the dermatology, multispeciality, and hospital groups in the area (yes, write them a nice snail mail letter) indicating you are interested, and ask them if they are hiring. Practices are usually interested in a general dermatologist, or perhaps a Mohs surgeon or dermatopathologist, willing to practice general dermatology half time. For example, I know a very nice general dermatology practice in the Midwest that has been looking for the right derm-path/general derm for years. The days of strolling in and setting up an all-Mohs or all-dermpath practice are over, unless you buy out, or become employed by one of the older established specialist groups.

Ask the staff (and former physician employees if you can find them) lots of questions. See if their style of medicine suits you. See if their electronic health record system is fast or a major hindrance. Find out how many extenders you will be responsible for supervising.

And find out if they are considering selling out (selling you) to private equity. Private equity groups are a major new influence on the specialty, run a lot of ads, and hire a lot of graduating dermatologists. They offer more benefits and higher initial salaries. There is no free lunch, however, and these perks must be paid back with future earnings. The private equity groups take 20%-30% of profits “off the top” and your earnings will hit a ceiling at a level that is significantly lower than it would be in a solo practice or dermatology group. They also have long, detailed, ferocious contracts with penalty clauses and noncompetes from all outlets. More numerous advertisements are a negative tip off, but will give you an idea of which markets they think are promising with regard to need and payer mix. See what the private equity group’s private health insurance rates are. If they are significantly greater than Medicare rates, they deserve a second look, though few are. Remember that the senior physician who pitches for them in the lounge doesn’t work for free, but receives a significant bonus for getting you to sign.

If you find a great location, it is time for contract review. The first rule is that no contract is better than who you sign it with. If they are determined to mistreat you, they will – no matter the contract. I advise always having a graceful exit written into the contract specifying severance terms (if any), even if you never need this.

If you are ready to work hard and make more income, you should forgo the perks and go on a percentage of collections basis. If you are considering a place where they very much need dermatologists (sorry, not New York City), you may have some negotiating room and it is worth spending a few thousand dollars to ask a medical contract attorney to go over the contract for you, or even negotiate for you. Don’t overestimate your value, however, because you might negotiate your way right out of a job. The expanding scope of nurse practitioners and physician assistants have taken away much of your indispensability. While there is a shortage of dermatologists in most of the United States, there generally is no shortage of dermatology appointments.

When you start a new job you are not certain about, resist the urge to buy a big house and put down roots right away. You may need to move on if it doesn’t work out. You may want to work a few years, pay down school loans, save a little, and set up your own practice somewhere.

All things considered, these are exciting times and being a board-certified dermatologist is a wonderful place to be in the medical world. I am not at all sure if any of the proposed end-of-the-world health care plans will come true. And let me know if you are one of those New York City residents who struck out for the western frontier. Us fly-over-country folk have got to stick together!
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I frequently get requests from residents and relocating dermatologists for information on finding the right job. There is some useful material pertaining to this topic on the American Academy of Dermatology website, which I helped develop. This should help you decide whether you want to go solo, small group, large group, VA, or academic practice. These options all have certain advantages and drawbacks.

Your first decision should be where you want to practice geographically, which will determine many of the details of any practice situation. For instance, if you go where there is a shortage of dermatologists, you will be more welcome and more sought after. I will never forget sitting in a hospital break room in New York City after giving grand rounds with a large group of residents, who asked me about practice opportunities. I asked them where they wanted to practice. Every resident – first, second, and third year – indicated they wanted to stay in New York City. I had to laugh to myself. If there are any cities with a surplus of dermatologists, it’s the hip ones: New York, San Francisco, Los Angeles, Miami, and so on. If you can find a job there, it will be a “this is what everyone signs” contract situation, and a large part of your pay is the privilege of living in an urban “paradise.”

If you are willing to look further afield, I suggest you start with an old classic, the “Places Rated Almanac: The Classic Guide for Finding Your Best Places to Live in America” (Washington: Places Rated Books, 2007). This is a resource (that needs a new edition) that provides all kinds of details on different areas of the country that you may not have considered, including median income, schools, climate, and livability.

When you know the general area where you would like to settle – and after considering the parents, the in-laws, and the outlaws – remember that the best jobs are not advertised. You should contact all the dermatology, multispeciality, and hospital groups in the area (yes, write them a nice snail mail letter) indicating you are interested, and ask them if they are hiring. Practices are usually interested in a general dermatologist, or perhaps a Mohs surgeon or dermatopathologist, willing to practice general dermatology half time. For example, I know a very nice general dermatology practice in the Midwest that has been looking for the right derm-path/general derm for years. The days of strolling in and setting up an all-Mohs or all-dermpath practice are over, unless you buy out, or become employed by one of the older established specialist groups.

Ask the staff (and former physician employees if you can find them) lots of questions. See if their style of medicine suits you. See if their electronic health record system is fast or a major hindrance. Find out how many extenders you will be responsible for supervising.

And find out if they are considering selling out (selling you) to private equity. Private equity groups are a major new influence on the specialty, run a lot of ads, and hire a lot of graduating dermatologists. They offer more benefits and higher initial salaries. There is no free lunch, however, and these perks must be paid back with future earnings. The private equity groups take 20%-30% of profits “off the top” and your earnings will hit a ceiling at a level that is significantly lower than it would be in a solo practice or dermatology group. They also have long, detailed, ferocious contracts with penalty clauses and noncompetes from all outlets. More numerous advertisements are a negative tip off, but will give you an idea of which markets they think are promising with regard to need and payer mix. See what the private equity group’s private health insurance rates are. If they are significantly greater than Medicare rates, they deserve a second look, though few are. Remember that the senior physician who pitches for them in the lounge doesn’t work for free, but receives a significant bonus for getting you to sign.

If you find a great location, it is time for contract review. The first rule is that no contract is better than who you sign it with. If they are determined to mistreat you, they will – no matter the contract. I advise always having a graceful exit written into the contract specifying severance terms (if any), even if you never need this.

If you are ready to work hard and make more income, you should forgo the perks and go on a percentage of collections basis. If you are considering a place where they very much need dermatologists (sorry, not New York City), you may have some negotiating room and it is worth spending a few thousand dollars to ask a medical contract attorney to go over the contract for you, or even negotiate for you. Don’t overestimate your value, however, because you might negotiate your way right out of a job. The expanding scope of nurse practitioners and physician assistants have taken away much of your indispensability. While there is a shortage of dermatologists in most of the United States, there generally is no shortage of dermatology appointments.

When you start a new job you are not certain about, resist the urge to buy a big house and put down roots right away. You may need to move on if it doesn’t work out. You may want to work a few years, pay down school loans, save a little, and set up your own practice somewhere.

All things considered, these are exciting times and being a board-certified dermatologist is a wonderful place to be in the medical world. I am not at all sure if any of the proposed end-of-the-world health care plans will come true. And let me know if you are one of those New York City residents who struck out for the western frontier. Us fly-over-country folk have got to stick together!
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

Unreasonable step therapy and prior authorizations, overly expensive generic drugs, opposition to a 5-year Medicare pay freeze, surprise medical billing, and the risks and benefits of sunscreen use for the prevention of skin cancer.

These were just some of the hot button issues that 156 of my fellow dermatologists brought before a record-breaking American Academy of Dermatology Association Legislative Conference in Washington. We also were joined by 49 patients and practice administrators for this terrific meeting filled with classes and speakers. Members of Congress joined us at various sessions and social occasions with good food, fine wine, and great conversations. Radio personality and CNN host Michael Smerconish gave a very funny speech at dinner and had comments about civility in politics. The comradery was excellent and the intellectual food for thought was extraordinary – right up the alley of dermatologists who are also political junkies.

Most congressional representatives are not well versed in health care topics. As a result, we spent a good deal of time on education – speaking to junior staffers who are expected to keep the members of Congress updated on what they need to know about medical and, specifically, dermatologic issues. As many refer to Washington as “the swamp,” you can consider the House members to be the “big gators,” and the staffers the ”little gators.” Taking that analogy further, lobbying (or educating) then logically becomes “gator wrestling.”

Most of the time we met with little gators, although this year we also met with 84 big gators. We took turns telling them true stories based on our patients’ problems with abuses within our health care system. I think these stories are effective. This is your representative government in action!

On the last day of the conference, we made personal calls by state on the hill offices. Some groups, like Ohio, were nine strong! Everyone gets to speak. This year’s meeting was attended by a total of 31 dermatology residents, and the residents from Ohio State and Cleveland Clinic who participated in our state meetings were terrific. In all, we covered 228 offices – 157 Congressional and 71 Senate.

Rep. John Joyce, MD, FAAD (R-PA-13) was on hand and is the first dermatologist elected for a full term to Congress. Anyone at the meeting could have spent all the time they wanted with him discussing our issues. He is most knowledgeable and a great asset for our specialty. Dr. Joyce is recognized as a dermatologist by his fellow representatives, and even by Speaker Nancy Pelosi and President Trump. For 30 years, Dr. Joyce has been a proud member of the American Academy of Dermatology, as is his wife Dr. Alice Joyce, who also is a dermatologist and continues to run their practice, Altoona Dermatology Associates.

Dr. Joyce is a true asset to dermatology. As an individual, I advocate supporting his campaign financially if you get the chance, beyond just what SkinPAC can give him.

In sum, the AADA Legislative Conference is a lot of productive fun. You get to network with all the leaders of the AAD, as well as many of the leaders of the United States. If you donate $5,000 to SkinPAC, they will pay your way to the conference. If you contribute $1,000, you get to go to the high-donor dinner (The same goes for a $50 donation from residents, no typo!). What’s not to like about that? Most dermatologists like a good party. Next year’s meeting is Sept. 13-15, 2020. See you there!
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].


 

Unreasonable step therapy and prior authorizations, overly expensive generic drugs, opposition to a 5-year Medicare pay freeze, surprise medical billing, and the risks and benefits of sunscreen use for the prevention of skin cancer.

These were just some of the hot button issues that 156 of my fellow dermatologists brought before a record-breaking American Academy of Dermatology Association Legislative Conference in Washington. We also were joined by 49 patients and practice administrators for this terrific meeting filled with classes and speakers. Members of Congress joined us at various sessions and social occasions with good food, fine wine, and great conversations. Radio personality and CNN host Michael Smerconish gave a very funny speech at dinner and had comments about civility in politics. The comradery was excellent and the intellectual food for thought was extraordinary – right up the alley of dermatologists who are also political junkies.

Most congressional representatives are not well versed in health care topics. As a result, we spent a good deal of time on education – speaking to junior staffers who are expected to keep the members of Congress updated on what they need to know about medical and, specifically, dermatologic issues. As many refer to Washington as “the swamp,” you can consider the House members to be the “big gators,” and the staffers the ”little gators.” Taking that analogy further, lobbying (or educating) then logically becomes “gator wrestling.”

Most of the time we met with little gators, although this year we also met with 84 big gators. We took turns telling them true stories based on our patients’ problems with abuses within our health care system. I think these stories are effective. This is your representative government in action!

On the last day of the conference, we made personal calls by state on the hill offices. Some groups, like Ohio, were nine strong! Everyone gets to speak. This year’s meeting was attended by a total of 31 dermatology residents, and the residents from Ohio State and Cleveland Clinic who participated in our state meetings were terrific. In all, we covered 228 offices – 157 Congressional and 71 Senate.

Rep. John Joyce, MD, FAAD (R-PA-13) was on hand and is the first dermatologist elected for a full term to Congress. Anyone at the meeting could have spent all the time they wanted with him discussing our issues. He is most knowledgeable and a great asset for our specialty. Dr. Joyce is recognized as a dermatologist by his fellow representatives, and even by Speaker Nancy Pelosi and President Trump. For 30 years, Dr. Joyce has been a proud member of the American Academy of Dermatology, as is his wife Dr. Alice Joyce, who also is a dermatologist and continues to run their practice, Altoona Dermatology Associates.

Dr. Joyce is a true asset to dermatology. As an individual, I advocate supporting his campaign financially if you get the chance, beyond just what SkinPAC can give him.

In sum, the AADA Legislative Conference is a lot of productive fun. You get to network with all the leaders of the AAD, as well as many of the leaders of the United States. If you donate $5,000 to SkinPAC, they will pay your way to the conference. If you contribute $1,000, you get to go to the high-donor dinner (The same goes for a $50 donation from residents, no typo!). What’s not to like about that? Most dermatologists like a good party. Next year’s meeting is Sept. 13-15, 2020. See you there!
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].


 

Unreasonable step therapy and prior authorizations, overly expensive generic drugs, opposition to a 5-year Medicare pay freeze, surprise medical billing, and the risks and benefits of sunscreen use for the prevention of skin cancer.

These were just some of the hot button issues that 156 of my fellow dermatologists brought before a record-breaking American Academy of Dermatology Association Legislative Conference in Washington. We also were joined by 49 patients and practice administrators for this terrific meeting filled with classes and speakers. Members of Congress joined us at various sessions and social occasions with good food, fine wine, and great conversations. Radio personality and CNN host Michael Smerconish gave a very funny speech at dinner and had comments about civility in politics. The comradery was excellent and the intellectual food for thought was extraordinary – right up the alley of dermatologists who are also political junkies.

Most congressional representatives are not well versed in health care topics. As a result, we spent a good deal of time on education – speaking to junior staffers who are expected to keep the members of Congress updated on what they need to know about medical and, specifically, dermatologic issues. As many refer to Washington as “the swamp,” you can consider the House members to be the “big gators,” and the staffers the ”little gators.” Taking that analogy further, lobbying (or educating) then logically becomes “gator wrestling.”

Most of the time we met with little gators, although this year we also met with 84 big gators. We took turns telling them true stories based on our patients’ problems with abuses within our health care system. I think these stories are effective. This is your representative government in action!

On the last day of the conference, we made personal calls by state on the hill offices. Some groups, like Ohio, were nine strong! Everyone gets to speak. This year’s meeting was attended by a total of 31 dermatology residents, and the residents from Ohio State and Cleveland Clinic who participated in our state meetings were terrific. In all, we covered 228 offices – 157 Congressional and 71 Senate.

Rep. John Joyce, MD, FAAD (R-PA-13) was on hand and is the first dermatologist elected for a full term to Congress. Anyone at the meeting could have spent all the time they wanted with him discussing our issues. He is most knowledgeable and a great asset for our specialty. Dr. Joyce is recognized as a dermatologist by his fellow representatives, and even by Speaker Nancy Pelosi and President Trump. For 30 years, Dr. Joyce has been a proud member of the American Academy of Dermatology, as is his wife Dr. Alice Joyce, who also is a dermatologist and continues to run their practice, Altoona Dermatology Associates.

Dr. Joyce is a true asset to dermatology. As an individual, I advocate supporting his campaign financially if you get the chance, beyond just what SkinPAC can give him.

In sum, the AADA Legislative Conference is a lot of productive fun. You get to network with all the leaders of the AAD, as well as many of the leaders of the United States. If you donate $5,000 to SkinPAC, they will pay your way to the conference. If you contribute $1,000, you get to go to the high-donor dinner (The same goes for a $50 donation from residents, no typo!). What’s not to like about that? Most dermatologists like a good party. Next year’s meeting is Sept. 13-15, 2020. See you there!
 

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].


 

I jumped in the cab and told the driver to take me straight to hell. “Oh,” he said. “You mean LaGuardia?” He was correct, of course.

It takes me just as long to get to LaGuardia from a hotel in midtown Manhattan as it does for me to fly from Cincinnati to New York. And once you are at the airport, it’s a hot mess. I hear that the terminal update at LaGuardia will be finished in 4 years. This is going to cost $8 billion, plus another $2 billion for an elevated train that connects to the railroad and subway.

Cincinnati built itself a streetcar to nowhere after the city council made a field trip to Portlandia. It was fueled by $45 million in federal “stimulus” grants, disrupted downtown for 9 years instead of 3, and cost $145 million instead of $110.

No one rides the streetcar. It is regularly delayed by people parking on the tracks, and collisions with cars happen regularly. In fact, checking to see if anyone buys a ticket was determined to not be cost effective. The city government cannot close the streetcar for 20 years because the city would otherwise have to give back the $45 million grant used to build it.

How do such boondoggles happen? It was all explained in a book given to me by a new friend in New York. “The Death of Common Sense,” by Philip K. Howard, spells it out.

If you want to fix a problem in any city you must run a gauntlet of meetings and meet regulations, many of which have nothing to do with engineering, quality, or safety. Expect action or approval to take years.

The “you can’t be too careful” movement has assumed a life of its own.

Of course, the same process is true in medicine, only more so! Human lives are at stake, so absolutely no chances can be taken. Medicine is not engineering. And the science of medicine is often so inexact that no one knows when they are taking a chance, or what is the right or wrong thing to do. The paperwork and rules become enormous. The regulations proliferate.

The resulting health care administration costs account for about 25% of health care dollars.

In one recent “you can’t be too careful” moment, I had a Joint Commission inspector tell me he was concerned about patients falling off our power tables when we perform procedures under local anesthesia. Now this has never happened in the last 30 years, but you can’t be too careful! I jokingly suggested we consider giant Velcro straps for the tables, and added that they would be particularly useful for the front office staff chairs. The inspector got excited. He thought giant Velcro straps were a great idea. I am now searching online for giant Velcro straps.

Several years ago, I had a clinical lab improvement inspection and everything was perfect. The inspectors could not find anything wrong, but they had allocated a half day for the inspection. They cast about, and finally insisted I buy a red stamper to indicate on the Mohs maps that the case was clear. I pointed out that a straight line though the map indicated the same thing, and even showed them the colored key codes on the back. No, we must have a red stamp! Now we stamp all the maps, sometimes several times! You can’t be too careful! To head off our next “what can we find” moment, we make sure we leave an expired bottle of stain or tissue dye in the back of the cabinet for the inspectors to find.

Pathologists are expected to report melanomas to the state, but we found out that they were behind in their reporting. So we thought we might help them out with the reporting. What were we thinking!? Upon investigation we obtained an online form that is almost incomprehensible and takes at least an hour to fill out. The form must be submitted online and completed in its entirety. There is a 4-hour webinar to help teach you how to fill it out. I called the state health department to ask for help, I was directed to the webinar, and was told in no uncertain terms that it is serious crime not to report melanoma. Thanks! I will be sure to tell the pathologist.

So avoid LaGuardia Airport for at least 4 more years, come ride the Cincinnati streetcar where you really don’t need a ticket, always leave something small for the inspector to find (mum’s the word), and let me know if you find any giant Velcro straps for sale online!

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I jumped in the cab and told the driver to take me straight to hell. “Oh,” he said. “You mean LaGuardia?” He was correct, of course.

It takes me just as long to get to LaGuardia from a hotel in midtown Manhattan as it does for me to fly from Cincinnati to New York. And once you are at the airport, it’s a hot mess. I hear that the terminal update at LaGuardia will be finished in 4 years. This is going to cost $8 billion, plus another $2 billion for an elevated train that connects to the railroad and subway.

Cincinnati built itself a streetcar to nowhere after the city council made a field trip to Portlandia. It was fueled by $45 million in federal “stimulus” grants, disrupted downtown for 9 years instead of 3, and cost $145 million instead of $110.

No one rides the streetcar. It is regularly delayed by people parking on the tracks, and collisions with cars happen regularly. In fact, checking to see if anyone buys a ticket was determined to not be cost effective. The city government cannot close the streetcar for 20 years because the city would otherwise have to give back the $45 million grant used to build it.

How do such boondoggles happen? It was all explained in a book given to me by a new friend in New York. “The Death of Common Sense,” by Philip K. Howard, spells it out.

If you want to fix a problem in any city you must run a gauntlet of meetings and meet regulations, many of which have nothing to do with engineering, quality, or safety. Expect action or approval to take years.

The “you can’t be too careful” movement has assumed a life of its own.

Of course, the same process is true in medicine, only more so! Human lives are at stake, so absolutely no chances can be taken. Medicine is not engineering. And the science of medicine is often so inexact that no one knows when they are taking a chance, or what is the right or wrong thing to do. The paperwork and rules become enormous. The regulations proliferate.

The resulting health care administration costs account for about 25% of health care dollars.

In one recent “you can’t be too careful” moment, I had a Joint Commission inspector tell me he was concerned about patients falling off our power tables when we perform procedures under local anesthesia. Now this has never happened in the last 30 years, but you can’t be too careful! I jokingly suggested we consider giant Velcro straps for the tables, and added that they would be particularly useful for the front office staff chairs. The inspector got excited. He thought giant Velcro straps were a great idea. I am now searching online for giant Velcro straps.

Several years ago, I had a clinical lab improvement inspection and everything was perfect. The inspectors could not find anything wrong, but they had allocated a half day for the inspection. They cast about, and finally insisted I buy a red stamper to indicate on the Mohs maps that the case was clear. I pointed out that a straight line though the map indicated the same thing, and even showed them the colored key codes on the back. No, we must have a red stamp! Now we stamp all the maps, sometimes several times! You can’t be too careful! To head off our next “what can we find” moment, we make sure we leave an expired bottle of stain or tissue dye in the back of the cabinet for the inspectors to find.

Pathologists are expected to report melanomas to the state, but we found out that they were behind in their reporting. So we thought we might help them out with the reporting. What were we thinking!? Upon investigation we obtained an online form that is almost incomprehensible and takes at least an hour to fill out. The form must be submitted online and completed in its entirety. There is a 4-hour webinar to help teach you how to fill it out. I called the state health department to ask for help, I was directed to the webinar, and was told in no uncertain terms that it is serious crime not to report melanoma. Thanks! I will be sure to tell the pathologist.

So avoid LaGuardia Airport for at least 4 more years, come ride the Cincinnati streetcar where you really don’t need a ticket, always leave something small for the inspector to find (mum’s the word), and let me know if you find any giant Velcro straps for sale online!

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].

I jumped in the cab and told the driver to take me straight to hell. “Oh,” he said. “You mean LaGuardia?” He was correct, of course.

It takes me just as long to get to LaGuardia from a hotel in midtown Manhattan as it does for me to fly from Cincinnati to New York. And once you are at the airport, it’s a hot mess. I hear that the terminal update at LaGuardia will be finished in 4 years. This is going to cost $8 billion, plus another $2 billion for an elevated train that connects to the railroad and subway.

Cincinnati built itself a streetcar to nowhere after the city council made a field trip to Portlandia. It was fueled by $45 million in federal “stimulus” grants, disrupted downtown for 9 years instead of 3, and cost $145 million instead of $110.

No one rides the streetcar. It is regularly delayed by people parking on the tracks, and collisions with cars happen regularly. In fact, checking to see if anyone buys a ticket was determined to not be cost effective. The city government cannot close the streetcar for 20 years because the city would otherwise have to give back the $45 million grant used to build it.

How do such boondoggles happen? It was all explained in a book given to me by a new friend in New York. “The Death of Common Sense,” by Philip K. Howard, spells it out.

If you want to fix a problem in any city you must run a gauntlet of meetings and meet regulations, many of which have nothing to do with engineering, quality, or safety. Expect action or approval to take years.

The “you can’t be too careful” movement has assumed a life of its own.

Of course, the same process is true in medicine, only more so! Human lives are at stake, so absolutely no chances can be taken. Medicine is not engineering. And the science of medicine is often so inexact that no one knows when they are taking a chance, or what is the right or wrong thing to do. The paperwork and rules become enormous. The regulations proliferate.

The resulting health care administration costs account for about 25% of health care dollars.

In one recent “you can’t be too careful” moment, I had a Joint Commission inspector tell me he was concerned about patients falling off our power tables when we perform procedures under local anesthesia. Now this has never happened in the last 30 years, but you can’t be too careful! I jokingly suggested we consider giant Velcro straps for the tables, and added that they would be particularly useful for the front office staff chairs. The inspector got excited. He thought giant Velcro straps were a great idea. I am now searching online for giant Velcro straps.

Several years ago, I had a clinical lab improvement inspection and everything was perfect. The inspectors could not find anything wrong, but they had allocated a half day for the inspection. They cast about, and finally insisted I buy a red stamper to indicate on the Mohs maps that the case was clear. I pointed out that a straight line though the map indicated the same thing, and even showed them the colored key codes on the back. No, we must have a red stamp! Now we stamp all the maps, sometimes several times! You can’t be too careful! To head off our next “what can we find” moment, we make sure we leave an expired bottle of stain or tissue dye in the back of the cabinet for the inspectors to find.

Pathologists are expected to report melanomas to the state, but we found out that they were behind in their reporting. So we thought we might help them out with the reporting. What were we thinking!? Upon investigation we obtained an online form that is almost incomprehensible and takes at least an hour to fill out. The form must be submitted online and completed in its entirety. There is a 4-hour webinar to help teach you how to fill it out. I called the state health department to ask for help, I was directed to the webinar, and was told in no uncertain terms that it is serious crime not to report melanoma. Thanks! I will be sure to tell the pathologist.

So avoid LaGuardia Airport for at least 4 more years, come ride the Cincinnati streetcar where you really don’t need a ticket, always leave something small for the inspector to find (mum’s the word), and let me know if you find any giant Velcro straps for sale online!

Dr. Coldiron is in private practice but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. He is a past president of the American Academy of Dermatology. Write to him at [email protected].