Commentary

The Centers for Disease Control and Prevention recently released data regarding the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs), in adolescents, and suggested ways to increase their use. The American Congress of Obstetricians and Gynecologists then reiterated its recommendation promoting the use of LARC in adolescents (Obstet Gynecol. 2012;120:983-8). Historically, the use of IUDs in nulliparous females was concerning because of the risk of pelvic inflammatory disease (which could lead to infertility), pain at insertion, and the cost. But more recent research has dispelled many of those concerns, and new legislation has made access and affordability a reality; hence, the use of IUDs in teens was recommended. Despite these advances, physicians still are not making teens aware of this method of contraception.

In 2013, two important things occurred. First, emergency contraception was made available over the counter without age restriction. Second, the Affordable Care Act required most private insurance plans to cover at least one type of all 18 Food and Drug Administration–approved contraceptive methods for women as prescribed without cost sharing; this reduced the barrier of cost for IUDs. For patients covered by Medicaid, details vary, but in many cases some type of IUD is covered. In considering the best method of contraception in teens, we can all agree contraception is only as good as its proper use. If we remove the concern of infertility secondary to pelvic inflammatory disease and the barrier of cost, we can make the argument that LARC is an ideal choice for young women.

Birth rates for teenagers fell 9% from 2013 to 2014, to 24.2 births per 1,000 females aged 15-19 years – a record low according to CDC data. The rate has declined 42% since 2007 and 61% since 1991. Considering that the percent of teens who engage in sexual activity has not changed, the cause of the decline has to be related to increased contraception use and education. Although rates have declined significantly, there is much work to be done to protect our teens from unintended pregnancies.

The Contraceptive Choice Project was designed to give teens the option of birth control with the barrier of cost removed. Sixty-nine percent of 10,000 girls aged 14-17 years chose the IUD (Am J Obstet Gynecol. 2010;203[2]:115.e1-e7). The Contraceptive Choice Project also stated that the teens in this study were 20 times more likely to become pregnant using oral contraceptives, the patch, or a vaginal ring, compared with LARC or an injectable contraceptive. That is a significant statistic given that the choice of birth control used is heavily dependent on the options available. As primary care physicians, we are likely the first line of intervention, so it is important that we do not exclude the options most likely to prevent unintended pregnancies.

The rate of adolescents using IUDs increased from 0.2 to 2.5 in the 2002 and 2006-2010 National Surveys of Family Growth (J Adolesc Health. 2013;53:401-6).

There are choices when it comes to IUDs. ParaGard and Mirena are most well known. ParaGard contains copper and is hormone free; it can be used as emergency contraception and can remain in place for 12 years. Mirena releases levonorgestrel, and can be left in place for 5 years; there now is a generic form. There has been hesitation in using this product in teens because of a marketing decision made when Mirena was brought to the U.S. market. The company sought FDA approval only for women who already had children to avoid concerns about fertility. But research shows IUDS are safe and effective in women of all ages.

Unlike birth control pills, Mirena and Paragard do not reduce acne. But Mirena does reduce bloating and cramping associated with periods. Paragard has unpredictable bleeding and, therefore, is a less favorable choice in women who are not restricted to hormone-free contraception.

Newer brands on the market are Skyla and Liletta. Both are comparable to Mirena but have lower amounts of hormone, so these IUDs will be less effective in controlling the cramping and bloating. Skyla, unlike Mirena, is marketed to teens.

Implementing birth control options in your practice is imperative in caring for adolescents. Bedsider.org is a wonderful website that reviews all forms of birth control, and the pros and cons associated with each; it also compares the different types to help young women make the best choice. Another useful website is thenationalcampaign.org; this website is dedicated to educating physicians, parents, and adolescents in birth control choices to reduce unplanned pregnancies.

Dr. Pearce is a pediatrician in Frankfort, Ill.

The Centers for Disease Control and Prevention recently released data regarding the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs), in adolescents, and suggested ways to increase their use. The American Congress of Obstetricians and Gynecologists then reiterated its recommendation promoting the use of LARC in adolescents (Obstet Gynecol. 2012;120:983-8). Historically, the use of IUDs in nulliparous females was concerning because of the risk of pelvic inflammatory disease (which could lead to infertility), pain at insertion, and the cost. But more recent research has dispelled many of those concerns, and new legislation has made access and affordability a reality; hence, the use of IUDs in teens was recommended. Despite these advances, physicians still are not making teens aware of this method of contraception.

In 2013, two important things occurred. First, emergency contraception was made available over the counter without age restriction. Second, the Affordable Care Act required most private insurance plans to cover at least one type of all 18 Food and Drug Administration–approved contraceptive methods for women as prescribed without cost sharing; this reduced the barrier of cost for IUDs. For patients covered by Medicaid, details vary, but in many cases some type of IUD is covered. In considering the best method of contraception in teens, we can all agree contraception is only as good as its proper use. If we remove the concern of infertility secondary to pelvic inflammatory disease and the barrier of cost, we can make the argument that LARC is an ideal choice for young women.

Birth rates for teenagers fell 9% from 2013 to 2014, to 24.2 births per 1,000 females aged 15-19 years – a record low according to CDC data. The rate has declined 42% since 2007 and 61% since 1991. Considering that the percent of teens who engage in sexual activity has not changed, the cause of the decline has to be related to increased contraception use and education. Although rates have declined significantly, there is much work to be done to protect our teens from unintended pregnancies.

The Contraceptive Choice Project was designed to give teens the option of birth control with the barrier of cost removed. Sixty-nine percent of 10,000 girls aged 14-17 years chose the IUD (Am J Obstet Gynecol. 2010;203[2]:115.e1-e7). The Contraceptive Choice Project also stated that the teens in this study were 20 times more likely to become pregnant using oral contraceptives, the patch, or a vaginal ring, compared with LARC or an injectable contraceptive. That is a significant statistic given that the choice of birth control used is heavily dependent on the options available. As primary care physicians, we are likely the first line of intervention, so it is important that we do not exclude the options most likely to prevent unintended pregnancies.

The rate of adolescents using IUDs increased from 0.2 to 2.5 in the 2002 and 2006-2010 National Surveys of Family Growth (J Adolesc Health. 2013;53:401-6).

There are choices when it comes to IUDs. ParaGard and Mirena are most well known. ParaGard contains copper and is hormone free; it can be used as emergency contraception and can remain in place for 12 years. Mirena releases levonorgestrel, and can be left in place for 5 years; there now is a generic form. There has been hesitation in using this product in teens because of a marketing decision made when Mirena was brought to the U.S. market. The company sought FDA approval only for women who already had children to avoid concerns about fertility. But research shows IUDS are safe and effective in women of all ages.

Unlike birth control pills, Mirena and Paragard do not reduce acne. But Mirena does reduce bloating and cramping associated with periods. Paragard has unpredictable bleeding and, therefore, is a less favorable choice in women who are not restricted to hormone-free contraception.

Newer brands on the market are Skyla and Liletta. Both are comparable to Mirena but have lower amounts of hormone, so these IUDs will be less effective in controlling the cramping and bloating. Skyla, unlike Mirena, is marketed to teens.

Implementing birth control options in your practice is imperative in caring for adolescents. Bedsider.org is a wonderful website that reviews all forms of birth control, and the pros and cons associated with each; it also compares the different types to help young women make the best choice. Another useful website is thenationalcampaign.org; this website is dedicated to educating physicians, parents, and adolescents in birth control choices to reduce unplanned pregnancies.

Dr. Pearce is a pediatrician in Frankfort, Ill.

The Centers for Disease Control and Prevention recently released data regarding the use of long-acting reversible contraception (LARC), specifically intrauterine devices (IUDs), in adolescents, and suggested ways to increase their use. The American Congress of Obstetricians and Gynecologists then reiterated its recommendation promoting the use of LARC in adolescents (Obstet Gynecol. 2012;120:983-8). Historically, the use of IUDs in nulliparous females was concerning because of the risk of pelvic inflammatory disease (which could lead to infertility), pain at insertion, and the cost. But more recent research has dispelled many of those concerns, and new legislation has made access and affordability a reality; hence, the use of IUDs in teens was recommended. Despite these advances, physicians still are not making teens aware of this method of contraception.

In 2013, two important things occurred. First, emergency contraception was made available over the counter without age restriction. Second, the Affordable Care Act required most private insurance plans to cover at least one type of all 18 Food and Drug Administration–approved contraceptive methods for women as prescribed without cost sharing; this reduced the barrier of cost for IUDs. For patients covered by Medicaid, details vary, but in many cases some type of IUD is covered. In considering the best method of contraception in teens, we can all agree contraception is only as good as its proper use. If we remove the concern of infertility secondary to pelvic inflammatory disease and the barrier of cost, we can make the argument that LARC is an ideal choice for young women.

Birth rates for teenagers fell 9% from 2013 to 2014, to 24.2 births per 1,000 females aged 15-19 years – a record low according to CDC data. The rate has declined 42% since 2007 and 61% since 1991. Considering that the percent of teens who engage in sexual activity has not changed, the cause of the decline has to be related to increased contraception use and education. Although rates have declined significantly, there is much work to be done to protect our teens from unintended pregnancies.

The Contraceptive Choice Project was designed to give teens the option of birth control with the barrier of cost removed. Sixty-nine percent of 10,000 girls aged 14-17 years chose the IUD (Am J Obstet Gynecol. 2010;203[2]:115.e1-e7). The Contraceptive Choice Project also stated that the teens in this study were 20 times more likely to become pregnant using oral contraceptives, the patch, or a vaginal ring, compared with LARC or an injectable contraceptive. That is a significant statistic given that the choice of birth control used is heavily dependent on the options available. As primary care physicians, we are likely the first line of intervention, so it is important that we do not exclude the options most likely to prevent unintended pregnancies.

The rate of adolescents using IUDs increased from 0.2 to 2.5 in the 2002 and 2006-2010 National Surveys of Family Growth (J Adolesc Health. 2013;53:401-6).

There are choices when it comes to IUDs. ParaGard and Mirena are most well known. ParaGard contains copper and is hormone free; it can be used as emergency contraception and can remain in place for 12 years. Mirena releases levonorgestrel, and can be left in place for 5 years; there now is a generic form. There has been hesitation in using this product in teens because of a marketing decision made when Mirena was brought to the U.S. market. The company sought FDA approval only for women who already had children to avoid concerns about fertility. But research shows IUDS are safe and effective in women of all ages.

Unlike birth control pills, Mirena and Paragard do not reduce acne. But Mirena does reduce bloating and cramping associated with periods. Paragard has unpredictable bleeding and, therefore, is a less favorable choice in women who are not restricted to hormone-free contraception.

Newer brands on the market are Skyla and Liletta. Both are comparable to Mirena but have lower amounts of hormone, so these IUDs will be less effective in controlling the cramping and bloating. Skyla, unlike Mirena, is marketed to teens.

Implementing birth control options in your practice is imperative in caring for adolescents. Bedsider.org is a wonderful website that reviews all forms of birth control, and the pros and cons associated with each; it also compares the different types to help young women make the best choice. Another useful website is thenationalcampaign.org; this website is dedicated to educating physicians, parents, and adolescents in birth control choices to reduce unplanned pregnancies.

Dr. Pearce is a pediatrician in Frankfort, Ill.

Chronic cough is defined by the American College of Chest Physicians as a cough lasting longer than 8 weeks. Chronic cough is a troubling disorder, mostly for the patients, who frequently make several outpatient visits to seek help for their symptoms, and whose quality of life can be severely impaired.

An algorithmic approach should be used in the diagnosis of chronic cough. Once we have ruled out the “bad actors” and have run through our nasal sprays, proton pump inhibitors, and antihistamines, it is time to get creative. Don’t neglect to provide lung cancer screening for your smokers – which, in the case of chronic cough, is actually case finding.

Dr. Peter G. Gibson of the University of Newcastle, Australia, and his colleagues published an article presenting some new concepts for chronic cough, an assessment tool, and a literature review on the use of gabapentin for this troubling disorder (Pulm Pharmacol Ther. 2015 Jul 2. pii:S1094-5539[15]00072-3).

The new concepts include laryngeal hypersensitivity, central reflex hypersensitivity, and cough hypersensitivity syndrome. The authors posit that these concepts reformulate into chronic cough as a neuropathic disorder, which may be amenable to treatment with neuromodulatory agents such as gabapentin.

I have several patients in my panel who might benefit from this therapy. But there are a couple of things to remember. First, gabapentin can be taken with food, but antacids decrease the bioavailability by 20% when taken together or up to 2 hours after gabapentin ingestion. Also, gabapentin has a wide therapeutic window, which will make it easier to find an individualized dose for our patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Chronic cough is defined by the American College of Chest Physicians as a cough lasting longer than 8 weeks. Chronic cough is a troubling disorder, mostly for the patients, who frequently make several outpatient visits to seek help for their symptoms, and whose quality of life can be severely impaired.

An algorithmic approach should be used in the diagnosis of chronic cough. Once we have ruled out the “bad actors” and have run through our nasal sprays, proton pump inhibitors, and antihistamines, it is time to get creative. Don’t neglect to provide lung cancer screening for your smokers – which, in the case of chronic cough, is actually case finding.

Dr. Peter G. Gibson of the University of Newcastle, Australia, and his colleagues published an article presenting some new concepts for chronic cough, an assessment tool, and a literature review on the use of gabapentin for this troubling disorder (Pulm Pharmacol Ther. 2015 Jul 2. pii:S1094-5539[15]00072-3).

The new concepts include laryngeal hypersensitivity, central reflex hypersensitivity, and cough hypersensitivity syndrome. The authors posit that these concepts reformulate into chronic cough as a neuropathic disorder, which may be amenable to treatment with neuromodulatory agents such as gabapentin.

I have several patients in my panel who might benefit from this therapy. But there are a couple of things to remember. First, gabapentin can be taken with food, but antacids decrease the bioavailability by 20% when taken together or up to 2 hours after gabapentin ingestion. Also, gabapentin has a wide therapeutic window, which will make it easier to find an individualized dose for our patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Chronic cough is defined by the American College of Chest Physicians as a cough lasting longer than 8 weeks. Chronic cough is a troubling disorder, mostly for the patients, who frequently make several outpatient visits to seek help for their symptoms, and whose quality of life can be severely impaired.

An algorithmic approach should be used in the diagnosis of chronic cough. Once we have ruled out the “bad actors” and have run through our nasal sprays, proton pump inhibitors, and antihistamines, it is time to get creative. Don’t neglect to provide lung cancer screening for your smokers – which, in the case of chronic cough, is actually case finding.

Dr. Peter G. Gibson of the University of Newcastle, Australia, and his colleagues published an article presenting some new concepts for chronic cough, an assessment tool, and a literature review on the use of gabapentin for this troubling disorder (Pulm Pharmacol Ther. 2015 Jul 2. pii:S1094-5539[15]00072-3).

The new concepts include laryngeal hypersensitivity, central reflex hypersensitivity, and cough hypersensitivity syndrome. The authors posit that these concepts reformulate into chronic cough as a neuropathic disorder, which may be amenable to treatment with neuromodulatory agents such as gabapentin.

I have several patients in my panel who might benefit from this therapy. But there are a couple of things to remember. First, gabapentin can be taken with food, but antacids decrease the bioavailability by 20% when taken together or up to 2 hours after gabapentin ingestion. Also, gabapentin has a wide therapeutic window, which will make it easier to find an individualized dose for our patients.

Dr. Ebbert is professor of medicine, a general internist at the Mayo Clinic in Rochester, Minn., and a diplomate of the American Board of Addiction Medicine. The opinions expressed are those of the author and do not necessarily represent the views and opinions of the Mayo Clinic. The opinions expressed in this article should not be used to diagnose or treat any medical condition, nor should they be used as a substitute for medical advice from a qualified, board-certified practicing clinician. Dr. Ebbert has no relevant financial disclosures about this article. Follow him on Twitter @jonebbert.

Over the last couple of years, I’ve written quite a lot about the trend toward consolidation. That trend shows no sign of abating; more and more soloists and small groups are selling or merging their practices with hospitals, multispecialty groups, or other large entities.

I have seen evidence, though, that many sellers are not receiving a fair price for the equity that they have worked so hard to build over several decades. If you are contemplating selling or merging, it is important that you not simply take the buyer’s word for how much your practice is worth. You need an impartial appraisal.

Of course, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 750 words; but three basic yardsticks are essential for a practice appraisal:

• Tangible assets. Equipment, cash, accounts receivable and other property owned by the practice.

• Liabilities. Accounts payable, outstanding loans, and anything else owed to others.

• Intangible assets. Sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the equity, or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular, but by no means the only method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll cover some sale and merger options that you may not have thought of next month.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Over the last couple of years, I’ve written quite a lot about the trend toward consolidation. That trend shows no sign of abating; more and more soloists and small groups are selling or merging their practices with hospitals, multispecialty groups, or other large entities.

I have seen evidence, though, that many sellers are not receiving a fair price for the equity that they have worked so hard to build over several decades. If you are contemplating selling or merging, it is important that you not simply take the buyer’s word for how much your practice is worth. You need an impartial appraisal.

Of course, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 750 words; but three basic yardsticks are essential for a practice appraisal:

• Tangible assets. Equipment, cash, accounts receivable and other property owned by the practice.

• Liabilities. Accounts payable, outstanding loans, and anything else owed to others.

• Intangible assets. Sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the equity, or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular, but by no means the only method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll cover some sale and merger options that you may not have thought of next month.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

Over the last couple of years, I’ve written quite a lot about the trend toward consolidation. That trend shows no sign of abating; more and more soloists and small groups are selling or merging their practices with hospitals, multispecialty groups, or other large entities.

I have seen evidence, though, that many sellers are not receiving a fair price for the equity that they have worked so hard to build over several decades. If you are contemplating selling or merging, it is important that you not simply take the buyer’s word for how much your practice is worth. You need an impartial appraisal.

Of course, a medical practice is trickier to value than an ordinary business, and usually requires the services of an experienced professional appraiser. Entire books have been written about the process, so I can’t hope to cover it completely in 750 words; but three basic yardsticks are essential for a practice appraisal:

• Tangible assets. Equipment, cash, accounts receivable and other property owned by the practice.

• Liabilities. Accounts payable, outstanding loans, and anything else owed to others.

• Intangible assets. Sometimes called “good will” – the reputation of the physicians, the location and name recognition of the practice, the loyalty and volume of patients, and other, well, intangibles.

Armed with those numbers, an appraiser can then determine the equity, or book value, of the practice.

Valuing tangible assets is comparatively straightforward, but there are several ways to do it, and when reviewing a practice appraisal you should ask which of them was used. Depreciated value is the book value of equipment and supplies as determined by their purchase price, less the amount their value has decreased since purchase. Remaining useful life value estimates how long the equipment can be expected to last. Market (or replacement) value is the amount it would cost on the open market to replace all equipment and supplies.

Intangible assets are more difficult to value. Many components are analyzed, including location, interior and exterior decor, accessibility to patients, age and functional status of equipment, systems in place to promote efficiency, reasons why patients come back (if in fact they do), and the overall reputation of the practice in the community. Other important factors include the “payer mix” (what percentage pays cash, how many third-party contracts are in place and how well they pay, etc.), the extent and strength of the referral base, and the presence of clinical studies or other supplemental income streams.

It is also important to determine to what extent intangible assets are transferable. For example, unique skills with a laser, neurotoxins, or filler substances, or extraordinary personal charisma, may increase your practice’s value to you, but they are worthless to the next owner, and he or she will be unwilling to pay for them unless your services become part of the deal.

Once again, there are many ways to estimate intangible asset value, and once again you should ask which were used. Cash Flow Analysis works on the assumption that cash flow is a measure of intangible value. Capitalization of Earnings puts a value, or capitalization, on the practice’s income streams using a variety of assumptions. Guideline Comparison uses various databases to compare your practice with other, similar ones that have changed hands in the past.

Two newer techniques, which some consider a better estimate of intangible assets, are the replacement method, which estimates the costs of starting the practice over again in the current market; and the excess earnings method, which measures how far above average your practice’s earnings (and thus its overall value) are.

Asset-based valuation is the most popular, but by no means the only method available. Income-based valuation looks at the source and strength of a practice’s income stream as a creator of value, as well as whether or not its income stream under a different owner would mirror its present one. This in turn becomes the basis for an understanding of the fair market value of both tangible and intangible assets. Market valuation combines the asset-based and income-based approaches, along with an analysis of sales and mergers of comparable practices in the community, to determine the value of a practice in its local market.

Whatever methods are used, it is important that the appraisal be done by an experienced financial consultant, that all techniques used in the valuation be divulged and explained, and that documentation is supplied to support the conclusions reached. This is especially important if the appraisal will be relied upon in the sale or merger of the practice. I’ll cover some sale and merger options that you may not have thought of next month.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters, and is a longtime monthly columnist for Dermatology News. Write to him at [email protected].

A couple made a baby boy. Into him they poured their hopes and dreams. But life is strange with its twists and turns, and things rarely go as planned.

The baby had a rough start. His brain was severely injured. The parents were told the chances of meaningful recovery were close to nothing. With heavy hearts but their son’s best interest in mind, they made the hardest decision of their lives – to provide for his comfort and nothing more. His life supports withdrawn, he was handed to them.

He did not die. Instead, he breathed. With that singular, definitive act, he proved his presence to them. They took him home, unsure what would come next. They did what anyone faced with such terrifying circumstances would have done – they fell in love with their baby. Their goals changed, but their love did not. Tinted by love, his staring spells became looks of cognizance, his reflexes became volitional motions. Think what you may, but do not judge them.

Unexpectedly, he has reached the age of 15 months. Through it all, the mother and father have been the perfect parents of a complex patient. But now he refuses to play the role of stable complex child. Instead, he is steadily worsening. It is easy for me to see this as I take ICU calls every fourth night. Not so for them. I don’t know what it feels like to build a dream and watch it crumble like sand, then to have to learn to carry on with what is left. I cannot imagine living a moment of their lives. Yet there they sit, next to him, waiting for rounds with smiling faces.

We are stuck. We wonder what’s in his best interest – to intervene with an invasive procedure that may allow him to go home or to withdraw interventions and provide him with comfort.

In my eyes, the real question is – where does he live? His parents believe that he is in the body lying on the bed. I can see why they feel this way – if he isn’t there, then what has any of this meant? Has he never been there? Did he leave sometime between defying death and creeping back toward it? These are frightening thoughts to face, indeed. And so, thoroughly entrenched, they must press on lest it be felt that they gave up on him.

I don’t know where he lives. Somewhere else? Heaven perhaps. In his parent’s memories for certain, and in my thoughts as well. In this limp body on the bed? I’m not so sure. But as he stares into his mother’s eyes, and jerks in response to her voice, I begin to doubt myself. How can I help them make this decision?

Perhaps this is the final lesson that residency will teach me.

No. I suspect I still won’t have an answer for the next parents I meet, once his story has played out. Only more questions. …

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth-Hitchcock, Lebanon, N.H., when he wrote this article. He is a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at [email protected].

A couple made a baby boy. Into him they poured their hopes and dreams. But life is strange with its twists and turns, and things rarely go as planned.

The baby had a rough start. His brain was severely injured. The parents were told the chances of meaningful recovery were close to nothing. With heavy hearts but their son’s best interest in mind, they made the hardest decision of their lives – to provide for his comfort and nothing more. His life supports withdrawn, he was handed to them.

He did not die. Instead, he breathed. With that singular, definitive act, he proved his presence to them. They took him home, unsure what would come next. They did what anyone faced with such terrifying circumstances would have done – they fell in love with their baby. Their goals changed, but their love did not. Tinted by love, his staring spells became looks of cognizance, his reflexes became volitional motions. Think what you may, but do not judge them.

Unexpectedly, he has reached the age of 15 months. Through it all, the mother and father have been the perfect parents of a complex patient. But now he refuses to play the role of stable complex child. Instead, he is steadily worsening. It is easy for me to see this as I take ICU calls every fourth night. Not so for them. I don’t know what it feels like to build a dream and watch it crumble like sand, then to have to learn to carry on with what is left. I cannot imagine living a moment of their lives. Yet there they sit, next to him, waiting for rounds with smiling faces.

We are stuck. We wonder what’s in his best interest – to intervene with an invasive procedure that may allow him to go home or to withdraw interventions and provide him with comfort.

In my eyes, the real question is – where does he live? His parents believe that he is in the body lying on the bed. I can see why they feel this way – if he isn’t there, then what has any of this meant? Has he never been there? Did he leave sometime between defying death and creeping back toward it? These are frightening thoughts to face, indeed. And so, thoroughly entrenched, they must press on lest it be felt that they gave up on him.

I don’t know where he lives. Somewhere else? Heaven perhaps. In his parent’s memories for certain, and in my thoughts as well. In this limp body on the bed? I’m not so sure. But as he stares into his mother’s eyes, and jerks in response to her voice, I begin to doubt myself. How can I help them make this decision?

Perhaps this is the final lesson that residency will teach me.

No. I suspect I still won’t have an answer for the next parents I meet, once his story has played out. Only more questions. …

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth-Hitchcock, Lebanon, N.H., when he wrote this article. He is a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at [email protected].

A couple made a baby boy. Into him they poured their hopes and dreams. But life is strange with its twists and turns, and things rarely go as planned.

The baby had a rough start. His brain was severely injured. The parents were told the chances of meaningful recovery were close to nothing. With heavy hearts but their son’s best interest in mind, they made the hardest decision of their lives – to provide for his comfort and nothing more. His life supports withdrawn, he was handed to them.

He did not die. Instead, he breathed. With that singular, definitive act, he proved his presence to them. They took him home, unsure what would come next. They did what anyone faced with such terrifying circumstances would have done – they fell in love with their baby. Their goals changed, but their love did not. Tinted by love, his staring spells became looks of cognizance, his reflexes became volitional motions. Think what you may, but do not judge them.

Unexpectedly, he has reached the age of 15 months. Through it all, the mother and father have been the perfect parents of a complex patient. But now he refuses to play the role of stable complex child. Instead, he is steadily worsening. It is easy for me to see this as I take ICU calls every fourth night. Not so for them. I don’t know what it feels like to build a dream and watch it crumble like sand, then to have to learn to carry on with what is left. I cannot imagine living a moment of their lives. Yet there they sit, next to him, waiting for rounds with smiling faces.

We are stuck. We wonder what’s in his best interest – to intervene with an invasive procedure that may allow him to go home or to withdraw interventions and provide him with comfort.

In my eyes, the real question is – where does he live? His parents believe that he is in the body lying on the bed. I can see why they feel this way – if he isn’t there, then what has any of this meant? Has he never been there? Did he leave sometime between defying death and creeping back toward it? These are frightening thoughts to face, indeed. And so, thoroughly entrenched, they must press on lest it be felt that they gave up on him.

I don’t know where he lives. Somewhere else? Heaven perhaps. In his parent’s memories for certain, and in my thoughts as well. In this limp body on the bed? I’m not so sure. But as he stares into his mother’s eyes, and jerks in response to her voice, I begin to doubt myself. How can I help them make this decision?

Perhaps this is the final lesson that residency will teach me.

No. I suspect I still won’t have an answer for the next parents I meet, once his story has played out. Only more questions. …

Dr. Behere was a pediatric resident at the Children’s Hospital at Dartmouth-Hitchcock, Lebanon, N.H., when he wrote this article. He is a first-year fellow in pediatric cardiology at the Nemours Cardiac Center at the Nemours/Alfred I. duPont Hospital for Children, Wilmington, Del. E-mail him at [email protected].

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

Recently, Niam Yaraghi of the Brookings Institution caused quite a kerfuffle regarding the validity of online doctor reviews in a U.S. News and World Report op-ed piece titled, “Don’t Yelp Your Doctor.”

In it, he argues that customers are “generally qualified and capable” of reviewing a restaurant – anyone can tell if a steak is chewy or a server is rude, he says. (Of course, chefs may disagree.) Yet, when it comes to online physician reviews, Mr. Yaraghi argues that “patients are neither qualified nor capable of evaluating the quality of the medical services that they receive.” I can see many of you nodding in vigorous agreement with that last sentence.

Who among us hasn’t felt indignant after reading a negative online review? Particularly one that criticizes our office decor or billing, yet makes no mention of our expert clinical abilities? But here’s my advice. Have your moment of indignation, then start working on improving your online reputation, which may improve your actual practice as well.

Here are a few tips for optimizing online physician review sites:

• Google yourself and your practice to see which sites your patients are commonly using.

• Set up a Google Alert at https://www.google.com/alerts. Google Alerts are email updates that you receive based on your queries. Include your name and the name of your practice. This way, you’ll receive notice when you’re mentioned online.

• According to SoftwareAdvice.com, the most trusted review sites in descending order are: Yelp and Healthgrades (tied), RateMDs, Vitals, ZocDoc, and others. So familiarize yourself with these sites.

• Claim your page on review sites. Be sure all of the information listed is updated and correct.

• Upload a professional photo of yourself. It’s much more effective to see a picture of you than an empty avatar.

• Be sure someone in your office is responsible for responding to comments online, particularly negative ones. It’s best to respond promptly rather than have it linger without a response for weeks. If you don’t write it, then at least approve it before it is posted.

• Respond to both positive and negative comments. Yelp, for instance, rewards business owners who maintain their site and actively respond to comments.

• For specific tips on how to respond to negative online reviews, see my column from July 2013 titled “How to handle negative reviews.”

When it comes to online physician reviews, I want you to remember a few things:

• Physician reviews are usually favorable.

• Negative reviews are sometimes opportunities to improve your service.

• In the long run, we should want more, not fewer, reviews. Which would you rather have, two negative reviews, or two negative reviews and eight positive ones?

• The more reviews you have, the more credible you appear to prospective patients. This is particularly true for cosmetic practices.

• Patients are more likely to leave a positive review when they see other positive reviews posted about you.

Let’s delve more deeply into the second point, “Negative reviews are opportunities for you and your staff to improve your service.”

According to the 2014 “IndustryView report” from Software Advice, when it came to administrative issues such as wait times, billing, and staff friendliness, 25% of respondents cited wait times as the most important factor in their experience. Moreover, their 2013 report found that 41% of patients said they would consider switching doctors if it reduced their wait times

We live in a consumer-centric society and service matters. For most patients, service equals quality. If you’ve got multiple negative reviews regarding your front desk staff, for instance, then address it directly with them. If you’ve got complaints about long wait times, then consider ways to improve it or improve the patient’s experience of waiting. You might hire a consultant to help with reducing wait times or you might provide Wi-Fi or light refreshments in your waiting room to make the wait more pleasant.

Let’s return to Mr. Yaraghi’s contention that patients are unqualified to accurately assess our abilities. It is a moot discussion. Patients have, and will continue, evaluating us regardless of how qualified they are to do so. A restaurant patron may not be an expert of sous-vide cooking but can judge his or her experience of the meal and restaurant staff. Similarly, a patient may not be an expert in psoriasis, but he or she can accurately assess an experience in our office and with our staff.

The good news is that there are sites that are trying to incorporate more objective data in the reviews. For instance, Healthgrades lists doctors’ board certifications, hospital affiliations, conditions treated, and procedures performed. The hope is that more objective criteria will improve the quality of the reviews and make the occasional angry and unwarranted rant less important.

One thing is for sure, there is much more discussion to come.

Dr. Benabio is a partner physician in the department of dermatology of the Southern California Permanente Group in San Diego, and a volunteer clinical assistant professor at the University of California, San Diego. Dr. Benabio is @dermdoc on Twitter.

White tea, like green tea, is derived from the plant Camellia sinensis, a member of the Theaceae family and the source of all the globally popular “true tea” beverages.

Of the four main true teas, green and white are unfermented (white is the least processed), black tea is fermented, and oolong tea is semifermented.^1,2,3 White tea actually comes from the tips of the green tea leaves or leaves that have not yet fully opened, with buds covered by fine white hair. As a commodity, white tea is more expensive than green tea because it is more difficult to obtain. EGCG [(-)epigallocatechin-3-O-gallate], the most abundant and biologically active polyphenolic catechin found in green tea, is also the constituent in white tea that accounts for its antioxidant properties.^4,5 Indeed, white tea is included in topical products for its antioxidant as well as antiseptic activity, and is considered a more potent antioxidant additive medium than green tea.^6,1

As an ingredient in a combination formula

White tea is included in the dietary supplement Imedeen Prime Renewal, along with fish protein polysaccharides, vitamins C and E, zinc, and extracts from soy, grape seed, chamomile, and tomato.

In 2006, Skovgaard et al. conducted a 6-month, double-blind, placebo-controlled randomized study on 80 healthy postmenopausal women (38 in the treatment group, 42 in the placebo group completed the study) to determine antiaging effects on the skin. Subjects took 2 tablets of the supplement or placebo twice daily. Clinical, photo, and ultrasound evaluations showed significantly greater improvements in the treatment group, compared with the placebo group, in the face (forehead, periocular, and perioral wrinkles; mottled pigmentation, laxity, sagging, dark circles under the eyes; and overall appearance), hands, and décolletage.⁷

Antioxidant and antiaging activity

In 2009, Thring et al. studied the antiaging and antioxidant characteristics of 23 plant extracts (from 21 species) by considering antielastase and anticollagenase activities. White tea was found to exhibit the greatest inhibitory activity against both elastase and collagenase, greater than burdock root and angelica in terms of antielastase activity, and greater than green tea, rose tincture, and lavender in relation to anticollagenase activity. The Trolox equivalent antioxidant capacity assay also showed that white tea displayed the highest antioxidant activity. The investigators noted the very high phenolic content of white tea in characterizing its potent inhibitory activity against enzymes that accelerate cutaneous aging.⁶

Earlier in 2009, Camouse et al. examined skin samples from volunteers or skin explants treated with topical white or green tea after ultraviolet exposure to ascertain that the antioxidant could prevent simulated solar radiation–induced damage to DNA and Langerhans cells. They noted that each product displayed a sun protection factor of 1, suggesting that the photoprotection conferred was not due to direct UV absorption. Both forms of topically applied tea extracts were equally effective and judged by the researchers to be potential photoprotective agents when used along with other substantiated approaches to skin protection. These findings provided the first reported evidence of topically applied white tea preventing UV-induced immunosuppression. The researchers further suggested that the color of white tea might render it more cosmetically desirable than green tea.⁸

It should be noted that a systematic review performed by Hunt et al. in 2010 of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and AMED (Allied and Complementary Medicine Database) databases up to 2009 identified 11 randomized clinical or controlled clinical trials evaluating the effectiveness of botanical extracts for diminishing wrinkling and other signs of cutaneous aging. No significant reductions in wrinkling were associated with the use of green tea or Vitaphenol (a combination of green and white teas, mangosteen, and pomegranate extract). The authors noted, however, that all of the trials that they identified were characterized by poor methodologic quality.⁹

Thring et al. conducted an in vitro study in 2011 to evaluate the antioxidant and anti-inflammatory activity of white tea, rose, and witch hazel extracts in primary human skin fibroblasts. The investigators measured significant anticollagenase, antielastase, and antioxidant activities for the white tea extracts, which also spurred a significant reduction in the interleukin-8 amount synthesized by fibroblasts, compared with controls. They concluded that white tea (as well as the other extracts) yielded a protective effect on fibroblasts against damage induced by hydrogen peroxide exposure.¹⁰

In 2014, Azman et al. used the spin trap method and electron paramagnetic resonance (EPR) spectroscopy to show that among white tea constituents, EGCG and epicatechin-3-gallate (ECG) exhibit the greatest antiradical activity against the methoxy radical.¹

Conclusion

Tea is one of the most popular beverages in the world and is touted for its antioxidant and anticancer properties. While the ingredients of green tea polyphenols have inspired a spate of recent research, much is yet to be learned about the potential health benefits of white tea, which is even less processed. Some evidence appears to suggest that white tea may be shown to be more effective overall, and in the dermatologic realm, than green tea. I look forward to seeing more research.

References

1. J Agric Food Chem. 2014;62(1):5743-8.

2. Dermatol Surg. 2005;31(7 Pt 2):873-80.

3. Oxid Med Cell Longev. 2012:2012:560682.

4. Mol Cell Biochem. 2000;206(1-2):125-32.

5. Free Radic Biol Med. 1999;26(11-12):1427-35.

6. BMC Complement Altern Med. 2009;9:27.

7. Eur J Clin Nutr. 2006;60(10):1201-6.

8. Exp Dermatol. 2009;18(6):522-6.

9. Drugs Aging. 2010;27(12):973-85.

10. J Inflamm (Lond). 2011;8(1):27).

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

White tea, like green tea, is derived from the plant Camellia sinensis, a member of the Theaceae family and the source of all the globally popular “true tea” beverages.

Of the four main true teas, green and white are unfermented (white is the least processed), black tea is fermented, and oolong tea is semifermented.^1,2,3 White tea actually comes from the tips of the green tea leaves or leaves that have not yet fully opened, with buds covered by fine white hair. As a commodity, white tea is more expensive than green tea because it is more difficult to obtain. EGCG [(-)epigallocatechin-3-O-gallate], the most abundant and biologically active polyphenolic catechin found in green tea, is also the constituent in white tea that accounts for its antioxidant properties.^4,5 Indeed, white tea is included in topical products for its antioxidant as well as antiseptic activity, and is considered a more potent antioxidant additive medium than green tea.^6,1

As an ingredient in a combination formula

White tea is included in the dietary supplement Imedeen Prime Renewal, along with fish protein polysaccharides, vitamins C and E, zinc, and extracts from soy, grape seed, chamomile, and tomato.

In 2006, Skovgaard et al. conducted a 6-month, double-blind, placebo-controlled randomized study on 80 healthy postmenopausal women (38 in the treatment group, 42 in the placebo group completed the study) to determine antiaging effects on the skin. Subjects took 2 tablets of the supplement or placebo twice daily. Clinical, photo, and ultrasound evaluations showed significantly greater improvements in the treatment group, compared with the placebo group, in the face (forehead, periocular, and perioral wrinkles; mottled pigmentation, laxity, sagging, dark circles under the eyes; and overall appearance), hands, and décolletage.⁷

Antioxidant and antiaging activity

In 2009, Thring et al. studied the antiaging and antioxidant characteristics of 23 plant extracts (from 21 species) by considering antielastase and anticollagenase activities. White tea was found to exhibit the greatest inhibitory activity against both elastase and collagenase, greater than burdock root and angelica in terms of antielastase activity, and greater than green tea, rose tincture, and lavender in relation to anticollagenase activity. The Trolox equivalent antioxidant capacity assay also showed that white tea displayed the highest antioxidant activity. The investigators noted the very high phenolic content of white tea in characterizing its potent inhibitory activity against enzymes that accelerate cutaneous aging.⁶

Earlier in 2009, Camouse et al. examined skin samples from volunteers or skin explants treated with topical white or green tea after ultraviolet exposure to ascertain that the antioxidant could prevent simulated solar radiation–induced damage to DNA and Langerhans cells. They noted that each product displayed a sun protection factor of 1, suggesting that the photoprotection conferred was not due to direct UV absorption. Both forms of topically applied tea extracts were equally effective and judged by the researchers to be potential photoprotective agents when used along with other substantiated approaches to skin protection. These findings provided the first reported evidence of topically applied white tea preventing UV-induced immunosuppression. The researchers further suggested that the color of white tea might render it more cosmetically desirable than green tea.⁸

It should be noted that a systematic review performed by Hunt et al. in 2010 of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and AMED (Allied and Complementary Medicine Database) databases up to 2009 identified 11 randomized clinical or controlled clinical trials evaluating the effectiveness of botanical extracts for diminishing wrinkling and other signs of cutaneous aging. No significant reductions in wrinkling were associated with the use of green tea or Vitaphenol (a combination of green and white teas, mangosteen, and pomegranate extract). The authors noted, however, that all of the trials that they identified were characterized by poor methodologic quality.⁹

Thring et al. conducted an in vitro study in 2011 to evaluate the antioxidant and anti-inflammatory activity of white tea, rose, and witch hazel extracts in primary human skin fibroblasts. The investigators measured significant anticollagenase, antielastase, and antioxidant activities for the white tea extracts, which also spurred a significant reduction in the interleukin-8 amount synthesized by fibroblasts, compared with controls. They concluded that white tea (as well as the other extracts) yielded a protective effect on fibroblasts against damage induced by hydrogen peroxide exposure.¹⁰

In 2014, Azman et al. used the spin trap method and electron paramagnetic resonance (EPR) spectroscopy to show that among white tea constituents, EGCG and epicatechin-3-gallate (ECG) exhibit the greatest antiradical activity against the methoxy radical.¹

Conclusion

Tea is one of the most popular beverages in the world and is touted for its antioxidant and anticancer properties. While the ingredients of green tea polyphenols have inspired a spate of recent research, much is yet to be learned about the potential health benefits of white tea, which is even less processed. Some evidence appears to suggest that white tea may be shown to be more effective overall, and in the dermatologic realm, than green tea. I look forward to seeing more research.

References

1. J Agric Food Chem. 2014;62(1):5743-8.

2. Dermatol Surg. 2005;31(7 Pt 2):873-80.

3. Oxid Med Cell Longev. 2012:2012:560682.

4. Mol Cell Biochem. 2000;206(1-2):125-32.

5. Free Radic Biol Med. 1999;26(11-12):1427-35.

6. BMC Complement Altern Med. 2009;9:27.

7. Eur J Clin Nutr. 2006;60(10):1201-6.

8. Exp Dermatol. 2009;18(6):522-6.

9. Drugs Aging. 2010;27(12):973-85.

10. J Inflamm (Lond). 2011;8(1):27).

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

White tea, like green tea, is derived from the plant Camellia sinensis, a member of the Theaceae family and the source of all the globally popular “true tea” beverages.

Of the four main true teas, green and white are unfermented (white is the least processed), black tea is fermented, and oolong tea is semifermented.^1,2,3 White tea actually comes from the tips of the green tea leaves or leaves that have not yet fully opened, with buds covered by fine white hair. As a commodity, white tea is more expensive than green tea because it is more difficult to obtain. EGCG [(-)epigallocatechin-3-O-gallate], the most abundant and biologically active polyphenolic catechin found in green tea, is also the constituent in white tea that accounts for its antioxidant properties.^4,5 Indeed, white tea is included in topical products for its antioxidant as well as antiseptic activity, and is considered a more potent antioxidant additive medium than green tea.^6,1

As an ingredient in a combination formula

White tea is included in the dietary supplement Imedeen Prime Renewal, along with fish protein polysaccharides, vitamins C and E, zinc, and extracts from soy, grape seed, chamomile, and tomato.

In 2006, Skovgaard et al. conducted a 6-month, double-blind, placebo-controlled randomized study on 80 healthy postmenopausal women (38 in the treatment group, 42 in the placebo group completed the study) to determine antiaging effects on the skin. Subjects took 2 tablets of the supplement or placebo twice daily. Clinical, photo, and ultrasound evaluations showed significantly greater improvements in the treatment group, compared with the placebo group, in the face (forehead, periocular, and perioral wrinkles; mottled pigmentation, laxity, sagging, dark circles under the eyes; and overall appearance), hands, and décolletage.⁷

Antioxidant and antiaging activity

In 2009, Thring et al. studied the antiaging and antioxidant characteristics of 23 plant extracts (from 21 species) by considering antielastase and anticollagenase activities. White tea was found to exhibit the greatest inhibitory activity against both elastase and collagenase, greater than burdock root and angelica in terms of antielastase activity, and greater than green tea, rose tincture, and lavender in relation to anticollagenase activity. The Trolox equivalent antioxidant capacity assay also showed that white tea displayed the highest antioxidant activity. The investigators noted the very high phenolic content of white tea in characterizing its potent inhibitory activity against enzymes that accelerate cutaneous aging.⁶

Earlier in 2009, Camouse et al. examined skin samples from volunteers or skin explants treated with topical white or green tea after ultraviolet exposure to ascertain that the antioxidant could prevent simulated solar radiation–induced damage to DNA and Langerhans cells. They noted that each product displayed a sun protection factor of 1, suggesting that the photoprotection conferred was not due to direct UV absorption. Both forms of topically applied tea extracts were equally effective and judged by the researchers to be potential photoprotective agents when used along with other substantiated approaches to skin protection. These findings provided the first reported evidence of topically applied white tea preventing UV-induced immunosuppression. The researchers further suggested that the color of white tea might render it more cosmetically desirable than green tea.⁸

It should be noted that a systematic review performed by Hunt et al. in 2010 of MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and AMED (Allied and Complementary Medicine Database) databases up to 2009 identified 11 randomized clinical or controlled clinical trials evaluating the effectiveness of botanical extracts for diminishing wrinkling and other signs of cutaneous aging. No significant reductions in wrinkling were associated with the use of green tea or Vitaphenol (a combination of green and white teas, mangosteen, and pomegranate extract). The authors noted, however, that all of the trials that they identified were characterized by poor methodologic quality.⁹

Thring et al. conducted an in vitro study in 2011 to evaluate the antioxidant and anti-inflammatory activity of white tea, rose, and witch hazel extracts in primary human skin fibroblasts. The investigators measured significant anticollagenase, antielastase, and antioxidant activities for the white tea extracts, which also spurred a significant reduction in the interleukin-8 amount synthesized by fibroblasts, compared with controls. They concluded that white tea (as well as the other extracts) yielded a protective effect on fibroblasts against damage induced by hydrogen peroxide exposure.¹⁰

In 2014, Azman et al. used the spin trap method and electron paramagnetic resonance (EPR) spectroscopy to show that among white tea constituents, EGCG and epicatechin-3-gallate (ECG) exhibit the greatest antiradical activity against the methoxy radical.¹

Conclusion

Tea is one of the most popular beverages in the world and is touted for its antioxidant and anticancer properties. While the ingredients of green tea polyphenols have inspired a spate of recent research, much is yet to be learned about the potential health benefits of white tea, which is even less processed. Some evidence appears to suggest that white tea may be shown to be more effective overall, and in the dermatologic realm, than green tea. I look forward to seeing more research.

References

1. J Agric Food Chem. 2014;62(1):5743-8.

2. Dermatol Surg. 2005;31(7 Pt 2):873-80.

3. Oxid Med Cell Longev. 2012:2012:560682.

4. Mol Cell Biochem. 2000;206(1-2):125-32.

5. Free Radic Biol Med. 1999;26(11-12):1427-35.

6. BMC Complement Altern Med. 2009;9:27.

7. Eur J Clin Nutr. 2006;60(10):1201-6.

8. Exp Dermatol. 2009;18(6):522-6.

9. Drugs Aging. 2010;27(12):973-85.

10. J Inflamm (Lond). 2011;8(1):27).

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].