Under My Skin

“So what do you do all day?”

Everyone asks that, right after they ask, “How do you like retirement?” I tell them I like it fine.

Asking what an emeritus does all day sounds fair, but the question is harder to answer than it sounds. Last year, I asked Dave, who was already retired. He took a day to think about it.

“Sometimes I sit on the back porch and watch the birds,” he said.

Dave has long been an avid bird-watcher. Along with golf and Facebook, watching birds is a pursuit that really engages many people, but I never understood it. I still don’t.

Over the years, I’ve met people whose experience of retirement has ranged from, “I’m so busy, I don’t know how I had time to work!” to, “I miss the gang and I’m bored,” to everything in between. Before I (semi-) retired, I made a plan to not make plans, at least at first: No new hobbies, cooking lessons, or anthropology courses. I figured I would figure it out.

So I am figuring it out. No rush. After a lifetime of rushing, not rushing is part of the point.

One hobby I cultivate is napping. I always get up early, no alarm needed. By late morning I am sometimes inclined to lie down for a bit. Taking a midmorning nap has always struck me as one of life’s great pleasures, though one I could rarely enjoy, unless you count dozing off standing up while a patient described an itch that started 17 years before, on a Thursday.

Now I can shut my eyes for half an hour and wake up refreshed, ready for the rest of the day.

During which I will do ...

An older friend of mine, now long gone, wrote a witty essay on being embarrassed to work at home. He refused to answer the phone during the day and hid from the postman. Contemplating retirement, I was afraid I would also feel that way, picturing myself a pitiful pensioner shuffling abroad at mid-day, looking for a park to poison pigeons in. That of course was before “working remotely” became a goal for cool young strivers. You see them around at all hours, with things sticking out of their ears, talking urgently to no one you can see.

Now I also walk the streets proudly at 11 a.m. or 2:45 p.m. I may get one of those earbuds that stick out at 45 degrees, so people can think my ear fungus has grown branches. Maybe they’ll imagine me a mastermind of an international CBD cartel. What they think doesn’t really matter.

One thing that I actually do all day is wonder why I spent so much of my career worrying about what other people think. Dr. Smith used to refer patients. No longer. Did I fail to meet her expectations? Mr. Trelawney came in weekly with itches and pains. No more. Did I roll my eyes too obviously?

Questions like these used to trouble me. Now I can’t recall why. Instead I worry about more important things, like who will play right field for the Red Sox this year.

Though I never signed up, I am an enrolled Baby Boomer, that navel-gazing cohort now passing from the scene while pretending it won’t. I never understood my generation when it was claiming to overturn the universe in the 1960s. Now its members write and read books with chirpy titles like “Amazing Aging!” as though – because we are so wonderfully special – age, infirmity, and decline will repeal themselves just for us.

Well, anyone can dream.

I go into the office a couple of half-days a week, when I’m in town. I like bantering with the gang and chatting with old patients. They wish me well and hope I’ll refer them to someone worthy when I hang them up for good, as many of their (and my) doctors already have.

Here is one thing I don’t do all day – manage human resource issues in the office. What’s to miss?

Now and then, with lessening frequency, I muse, “Well, if I do get bored, I can always spend more time in the office.”

Time for another nap.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semi-retired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

“So what do you do all day?”

Everyone asks that, right after they ask, “How do you like retirement?” I tell them I like it fine.

Asking what an emeritus does all day sounds fair, but the question is harder to answer than it sounds. Last year, I asked Dave, who was already retired. He took a day to think about it.

“Sometimes I sit on the back porch and watch the birds,” he said.

Dave has long been an avid bird-watcher. Along with golf and Facebook, watching birds is a pursuit that really engages many people, but I never understood it. I still don’t.

Over the years, I’ve met people whose experience of retirement has ranged from, “I’m so busy, I don’t know how I had time to work!” to, “I miss the gang and I’m bored,” to everything in between. Before I (semi-) retired, I made a plan to not make plans, at least at first: No new hobbies, cooking lessons, or anthropology courses. I figured I would figure it out.

So I am figuring it out. No rush. After a lifetime of rushing, not rushing is part of the point.

One hobby I cultivate is napping. I always get up early, no alarm needed. By late morning I am sometimes inclined to lie down for a bit. Taking a midmorning nap has always struck me as one of life’s great pleasures, though one I could rarely enjoy, unless you count dozing off standing up while a patient described an itch that started 17 years before, on a Thursday.

Now I can shut my eyes for half an hour and wake up refreshed, ready for the rest of the day.

During which I will do ...

An older friend of mine, now long gone, wrote a witty essay on being embarrassed to work at home. He refused to answer the phone during the day and hid from the postman. Contemplating retirement, I was afraid I would also feel that way, picturing myself a pitiful pensioner shuffling abroad at mid-day, looking for a park to poison pigeons in. That of course was before “working remotely” became a goal for cool young strivers. You see them around at all hours, with things sticking out of their ears, talking urgently to no one you can see.

Now I also walk the streets proudly at 11 a.m. or 2:45 p.m. I may get one of those earbuds that stick out at 45 degrees, so people can think my ear fungus has grown branches. Maybe they’ll imagine me a mastermind of an international CBD cartel. What they think doesn’t really matter.

One thing that I actually do all day is wonder why I spent so much of my career worrying about what other people think. Dr. Smith used to refer patients. No longer. Did I fail to meet her expectations? Mr. Trelawney came in weekly with itches and pains. No more. Did I roll my eyes too obviously?

Questions like these used to trouble me. Now I can’t recall why. Instead I worry about more important things, like who will play right field for the Red Sox this year.

Though I never signed up, I am an enrolled Baby Boomer, that navel-gazing cohort now passing from the scene while pretending it won’t. I never understood my generation when it was claiming to overturn the universe in the 1960s. Now its members write and read books with chirpy titles like “Amazing Aging!” as though – because we are so wonderfully special – age, infirmity, and decline will repeal themselves just for us.

Well, anyone can dream.

I go into the office a couple of half-days a week, when I’m in town. I like bantering with the gang and chatting with old patients. They wish me well and hope I’ll refer them to someone worthy when I hang them up for good, as many of their (and my) doctors already have.

Here is one thing I don’t do all day – manage human resource issues in the office. What’s to miss?

Now and then, with lessening frequency, I muse, “Well, if I do get bored, I can always spend more time in the office.”

Time for another nap.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semi-retired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

“So what do you do all day?”

Everyone asks that, right after they ask, “How do you like retirement?” I tell them I like it fine.

Asking what an emeritus does all day sounds fair, but the question is harder to answer than it sounds. Last year, I asked Dave, who was already retired. He took a day to think about it.

“Sometimes I sit on the back porch and watch the birds,” he said.

Dave has long been an avid bird-watcher. Along with golf and Facebook, watching birds is a pursuit that really engages many people, but I never understood it. I still don’t.

Over the years, I’ve met people whose experience of retirement has ranged from, “I’m so busy, I don’t know how I had time to work!” to, “I miss the gang and I’m bored,” to everything in between. Before I (semi-) retired, I made a plan to not make plans, at least at first: No new hobbies, cooking lessons, or anthropology courses. I figured I would figure it out.

So I am figuring it out. No rush. After a lifetime of rushing, not rushing is part of the point.

One hobby I cultivate is napping. I always get up early, no alarm needed. By late morning I am sometimes inclined to lie down for a bit. Taking a midmorning nap has always struck me as one of life’s great pleasures, though one I could rarely enjoy, unless you count dozing off standing up while a patient described an itch that started 17 years before, on a Thursday.

Now I can shut my eyes for half an hour and wake up refreshed, ready for the rest of the day.

During which I will do ...

An older friend of mine, now long gone, wrote a witty essay on being embarrassed to work at home. He refused to answer the phone during the day and hid from the postman. Contemplating retirement, I was afraid I would also feel that way, picturing myself a pitiful pensioner shuffling abroad at mid-day, looking for a park to poison pigeons in. That of course was before “working remotely” became a goal for cool young strivers. You see them around at all hours, with things sticking out of their ears, talking urgently to no one you can see.

Now I also walk the streets proudly at 11 a.m. or 2:45 p.m. I may get one of those earbuds that stick out at 45 degrees, so people can think my ear fungus has grown branches. Maybe they’ll imagine me a mastermind of an international CBD cartel. What they think doesn’t really matter.

One thing that I actually do all day is wonder why I spent so much of my career worrying about what other people think. Dr. Smith used to refer patients. No longer. Did I fail to meet her expectations? Mr. Trelawney came in weekly with itches and pains. No more. Did I roll my eyes too obviously?

Questions like these used to trouble me. Now I can’t recall why. Instead I worry about more important things, like who will play right field for the Red Sox this year.

Though I never signed up, I am an enrolled Baby Boomer, that navel-gazing cohort now passing from the scene while pretending it won’t. I never understood my generation when it was claiming to overturn the universe in the 1960s. Now its members write and read books with chirpy titles like “Amazing Aging!” as though – because we are so wonderfully special – age, infirmity, and decline will repeal themselves just for us.

Well, anyone can dream.

I go into the office a couple of half-days a week, when I’m in town. I like bantering with the gang and chatting with old patients. They wish me well and hope I’ll refer them to someone worthy when I hang them up for good, as many of their (and my) doctors already have.

Here is one thing I don’t do all day – manage human resource issues in the office. What’s to miss?

Now and then, with lessening frequency, I muse, “Well, if I do get bored, I can always spend more time in the office.”

Time for another nap.

Dr. Rockoff, who wrote the Dermatology News column “Under My Skin,” is now semi-retired, after 40 years of practice in Brookline, Mass. He served on the clinical faculty at Tufts University, Boston, and taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Dear Colleagues,

Forty years ago, dermatology practice was different. No patient came to the office for a “full-body check,” nor did anyone show up for hair removal or questions about cosmetic procedures or skin care advice.

Needle nippers were around, but no elaborate, molded-plastic contraptions like the sharps containers now in wide use. You sent pathology specimens in plastic cylinders by U.S. mail; then you called the lab 2 weeks later to ask, “Where’s the report on Jane Smith, with the rule out melanoma,” and the lab said, “Jane who?”

Of course, some things about practice have not changed. Patients with atopic dermatitis still ask why eczema comes back and why we can’t give them something to make it go away once and for all. Some referring physicians still treat scaly rashes with ketoconazole cream (and when that fails, oral fluconazole, which doesn’t work either).

Of course the biggest change between then and now, coincident with the rise of computers and technology, is the advent and ubiquity of that great swindle foisted upon the profession and the public – electronic health records – with their unfulfilled promises of cost-savings and efficiency and unconceded consequences: turning healers into harried data-entry drudges too busy clicking mice to make eye contact with humans. Yes, the Emperor has clothes. The Emperor is wearing Depends.

I wrote my first column for this periodical 22 years ago; this will be my last. My wonderful editor, Elizabeth Mechcatie, has agreed to take under advisement a proposal that I go on sending occasional dispatches under the heading “Pruritus Emeritus.” My family used to refer to those in the anomalous state of being emeritus – it means, roughly, “Forgotten, but not gone” – by rhyming emeritus with sinusitis.

There is no way to remember 40 years of patients. Many came just once, others several times. Some moved away, some passed away, changed primary doctors, changed insurances. Some grew too old to visit, sent regretful notes apologizing for finding the drive too long, the parking too hard. Some returned after an absence of a decade or 3, having forgotten that they had once come for the same problem, or come at all.

But there have been other patients who formed a real bond, whose names and faces still come readily to mind, who visited over long periods, sent their spouses, family members, even children and grandchildren. The stories of their lives became part of mine, and sometimes mine part of theirs.

Though hardly an old-movie buff, I know the famous scene in Casablanca in which a radiant Ingrid Bergman (that skin!) asks Dooley Wilson – the piano player, Sam – to play the song Humphrey Bogart does not want to hear:

“You must remember this

A kiss is just a kiss

A sigh is just a sigh

The fundamental things apply

As time goes by.”

Over the last 40 years there have been substantial advances in the way we treat patients, though perhaps not enough to justify the endless noisy hype about imminent breakthroughs and looming disruptions, therapies, and apps that are sure to change practice and civilization as we know them. Altogether too much noise, at least for my taste. But not inside the examining room.

Outside the room rages the din of demographic updates, of online checks of insurance eligibility, referral status, prior authorizations, the blare of marketing and promotion, the cacophony of metrics and algorithms.

Inside the room, however, quiet reigns. A patient presents with a symptom or a sign, or the fear of a symptom or anxiety over the meaning of a sign, filtered through a jumble of ideas – misremembered, half understood, at times mutually contradictory – that amplify fears common to anyone who visits a practitioner, however minor the presenting complaint: pain, debility, decline, isolation, solitude, death.

And the practitioner attends, considers, contextualizes, counsels, consoles, and conveys a response to the patient’s questions, whether in so many words or by body language or tone of voice, offers answers not just to what the patient has asked but the ones the patient meant to ask but did not know how.

“Yes, sir, death waits for all of us in the end, but for you, perhaps, not today.”

“Yes, madam, illness can be a frightening affair, but your case is not as bad as you think it is and won’t move as fast as you imagine. And as to your being limited and alone – well, not yet. There are those you can rely on, people with a bit of knowledge and a little experience, who are committed to doing what can be done to bend the arc of illness in your favor.”

That fundamental role will, it seems to me, always apply as long people practice medicine.

With all good wishes for personal happiness and professional success,

Alan Rockoff
 

Dear Colleagues,

Forty years ago, dermatology practice was different. No patient came to the office for a “full-body check,” nor did anyone show up for hair removal or questions about cosmetic procedures or skin care advice.

Needle nippers were around, but no elaborate, molded-plastic contraptions like the sharps containers now in wide use. You sent pathology specimens in plastic cylinders by U.S. mail; then you called the lab 2 weeks later to ask, “Where’s the report on Jane Smith, with the rule out melanoma,” and the lab said, “Jane who?”

Of course, some things about practice have not changed. Patients with atopic dermatitis still ask why eczema comes back and why we can’t give them something to make it go away once and for all. Some referring physicians still treat scaly rashes with ketoconazole cream (and when that fails, oral fluconazole, which doesn’t work either).

Of course the biggest change between then and now, coincident with the rise of computers and technology, is the advent and ubiquity of that great swindle foisted upon the profession and the public – electronic health records – with their unfulfilled promises of cost-savings and efficiency and unconceded consequences: turning healers into harried data-entry drudges too busy clicking mice to make eye contact with humans. Yes, the Emperor has clothes. The Emperor is wearing Depends.

I wrote my first column for this periodical 22 years ago; this will be my last. My wonderful editor, Elizabeth Mechcatie, has agreed to take under advisement a proposal that I go on sending occasional dispatches under the heading “Pruritus Emeritus.” My family used to refer to those in the anomalous state of being emeritus – it means, roughly, “Forgotten, but not gone” – by rhyming emeritus with sinusitis.

There is no way to remember 40 years of patients. Many came just once, others several times. Some moved away, some passed away, changed primary doctors, changed insurances. Some grew too old to visit, sent regretful notes apologizing for finding the drive too long, the parking too hard. Some returned after an absence of a decade or 3, having forgotten that they had once come for the same problem, or come at all.

But there have been other patients who formed a real bond, whose names and faces still come readily to mind, who visited over long periods, sent their spouses, family members, even children and grandchildren. The stories of their lives became part of mine, and sometimes mine part of theirs.

Though hardly an old-movie buff, I know the famous scene in Casablanca in which a radiant Ingrid Bergman (that skin!) asks Dooley Wilson – the piano player, Sam – to play the song Humphrey Bogart does not want to hear:

“You must remember this

A kiss is just a kiss

A sigh is just a sigh

The fundamental things apply

As time goes by.”

Over the last 40 years there have been substantial advances in the way we treat patients, though perhaps not enough to justify the endless noisy hype about imminent breakthroughs and looming disruptions, therapies, and apps that are sure to change practice and civilization as we know them. Altogether too much noise, at least for my taste. But not inside the examining room.

Outside the room rages the din of demographic updates, of online checks of insurance eligibility, referral status, prior authorizations, the blare of marketing and promotion, the cacophony of metrics and algorithms.

Inside the room, however, quiet reigns. A patient presents with a symptom or a sign, or the fear of a symptom or anxiety over the meaning of a sign, filtered through a jumble of ideas – misremembered, half understood, at times mutually contradictory – that amplify fears common to anyone who visits a practitioner, however minor the presenting complaint: pain, debility, decline, isolation, solitude, death.

And the practitioner attends, considers, contextualizes, counsels, consoles, and conveys a response to the patient’s questions, whether in so many words or by body language or tone of voice, offers answers not just to what the patient has asked but the ones the patient meant to ask but did not know how.

“Yes, sir, death waits for all of us in the end, but for you, perhaps, not today.”

“Yes, madam, illness can be a frightening affair, but your case is not as bad as you think it is and won’t move as fast as you imagine. And as to your being limited and alone – well, not yet. There are those you can rely on, people with a bit of knowledge and a little experience, who are committed to doing what can be done to bend the arc of illness in your favor.”

That fundamental role will, it seems to me, always apply as long people practice medicine.

With all good wishes for personal happiness and professional success,

Alan Rockoff
 

Dear Colleagues,

Forty years ago, dermatology practice was different. No patient came to the office for a “full-body check,” nor did anyone show up for hair removal or questions about cosmetic procedures or skin care advice.

Needle nippers were around, but no elaborate, molded-plastic contraptions like the sharps containers now in wide use. You sent pathology specimens in plastic cylinders by U.S. mail; then you called the lab 2 weeks later to ask, “Where’s the report on Jane Smith, with the rule out melanoma,” and the lab said, “Jane who?”

Of course, some things about practice have not changed. Patients with atopic dermatitis still ask why eczema comes back and why we can’t give them something to make it go away once and for all. Some referring physicians still treat scaly rashes with ketoconazole cream (and when that fails, oral fluconazole, which doesn’t work either).

Of course the biggest change between then and now, coincident with the rise of computers and technology, is the advent and ubiquity of that great swindle foisted upon the profession and the public – electronic health records – with their unfulfilled promises of cost-savings and efficiency and unconceded consequences: turning healers into harried data-entry drudges too busy clicking mice to make eye contact with humans. Yes, the Emperor has clothes. The Emperor is wearing Depends.

I wrote my first column for this periodical 22 years ago; this will be my last. My wonderful editor, Elizabeth Mechcatie, has agreed to take under advisement a proposal that I go on sending occasional dispatches under the heading “Pruritus Emeritus.” My family used to refer to those in the anomalous state of being emeritus – it means, roughly, “Forgotten, but not gone” – by rhyming emeritus with sinusitis.

There is no way to remember 40 years of patients. Many came just once, others several times. Some moved away, some passed away, changed primary doctors, changed insurances. Some grew too old to visit, sent regretful notes apologizing for finding the drive too long, the parking too hard. Some returned after an absence of a decade or 3, having forgotten that they had once come for the same problem, or come at all.

But there have been other patients who formed a real bond, whose names and faces still come readily to mind, who visited over long periods, sent their spouses, family members, even children and grandchildren. The stories of their lives became part of mine, and sometimes mine part of theirs.

Though hardly an old-movie buff, I know the famous scene in Casablanca in which a radiant Ingrid Bergman (that skin!) asks Dooley Wilson – the piano player, Sam – to play the song Humphrey Bogart does not want to hear:

“You must remember this

A kiss is just a kiss

A sigh is just a sigh

The fundamental things apply

As time goes by.”

Over the last 40 years there have been substantial advances in the way we treat patients, though perhaps not enough to justify the endless noisy hype about imminent breakthroughs and looming disruptions, therapies, and apps that are sure to change practice and civilization as we know them. Altogether too much noise, at least for my taste. But not inside the examining room.

Outside the room rages the din of demographic updates, of online checks of insurance eligibility, referral status, prior authorizations, the blare of marketing and promotion, the cacophony of metrics and algorithms.

Inside the room, however, quiet reigns. A patient presents with a symptom or a sign, or the fear of a symptom or anxiety over the meaning of a sign, filtered through a jumble of ideas – misremembered, half understood, at times mutually contradictory – that amplify fears common to anyone who visits a practitioner, however minor the presenting complaint: pain, debility, decline, isolation, solitude, death.

And the practitioner attends, considers, contextualizes, counsels, consoles, and conveys a response to the patient’s questions, whether in so many words or by body language or tone of voice, offers answers not just to what the patient has asked but the ones the patient meant to ask but did not know how.

“Yes, sir, death waits for all of us in the end, but for you, perhaps, not today.”

“Yes, madam, illness can be a frightening affair, but your case is not as bad as you think it is and won’t move as fast as you imagine. And as to your being limited and alone – well, not yet. There are those you can rely on, people with a bit of knowledge and a little experience, who are committed to doing what can be done to bend the arc of illness in your favor.”

That fundamental role will, it seems to me, always apply as long people practice medicine.

With all good wishes for personal happiness and professional success,

Alan Rockoff
 

Many patients have seen their long-term physicians retire. When I ask how they like their new doctors, they say: “She’s okay, I guess. Quite efficient. Seems thorough. But it’s not the same. It’s just business. Nothing personal.”

Sometimes you have to look backward to look forward. So it’s perhaps fitting that I glimpsed the future at my last colonoscopy.

In recent years, I’ve had such procedures at a local suburban surgicenter. Easy access, plenty of parking.

The woman who checks me in is all business. She scans my insurance cards and hands me a clipboard with a medical history form. Have I ever had cancer? A hernia? Am I pregnant? I wonder whether anyone reads these.

A different young woman brings me inside, the first of many new faces. Their roles are murky.

In a curtained cubby, yet another staff person asks me to pack my clothes in a plastic bag and put on a johnny. Then an older man enters, initiating furious multitasking. A different nursing assistant asks me to confirm my name and date of birth, then inserts an intravenous line in one arm, while the old doctor hands me an anesthesia consent form to sign with the other hand. I check many answers very fast, ignore the small-print boilerplate, and sign.

I am handed two more consent forms to sign, one from each side. The staff makes no pretense of explaining them or even telling me what they are for, and I make none of reading them.

They depart, replaced by still another person, who rolls me into the next room. He confirms my name and date of birth, and which procedure I am there for. The purpose of these multiple checks is clear, along with dispiriting depersonalization. One could mitigate this with some light banter, but no one bothers. No time.

My physician – whom I actually know – enters, says hello, and exchanges pleasantries. The last guy asks me to turn onto my left side. Intravenous sedation flows into my veins. The rest is silence.

Sometime later I wake up, greeted by another staff person. She asks if I am okay and offers me water or juice and saltines. Noting her Boston Red Sox sweatshirt, I say, “Great game last night,” but she does not know what I am talking about. She cares only for football and plans to fly to Nashville, Tenn., to watch her favorites.

Curtains are closed, and I am asked to dress. Another assistant directs me to a chair, where I will await my ride home. Through I try to walk alone, she takes my arm. “We assist everyone,” she explains.

As the sedation wears off, I observe. All around me I see movement, brisk and purposeful. Staff members crisscross before me from all angles, striding from one task to another, from prep room A to cubby D, walking with or pushing patients from procedure room M to holding area 8H. No one I’ve just met recognizes me, or acknowledges having met me before.

At last, the final staff member approaches. She flashes a kind smile as she takes my arm to walk me to the door. I take this for a personal touch, until she explains that she must make sure I don’t fall and that I get into the right car. As we pass, no one in the waiting room, neither staff nor patients, takes any notice.

My wife is outside, idling in the correct car. She’s brought coffee and a chocolate croissant, which – almost – makes last night’s prep worthwhile. She confirms neither my name nor date of birth.

Altogether, I have been in and out in 90 minutes. In the car, I peruse the handout that had been given to me as I exited. Drinking my coffee, I read the postcare instructions and enjoy its full-color pictures. Seldom has my cecum looked more radiant.

In “The Checklist Manifesto,” Atul Gawande described the outcome improvement that systematized practice can achieve. Data analysis confirms the measurably superior efficacy of such a method.

As for me, I feel like output from one of today’s cataract factories: like a car just extruded from an automated wash, with a photo on its front seat of the shiny, Simonized hubcaps included with the premium service package.

The medical care of the future? Okay, I guess. Seems efficient and thorough. Data confirm this.

Just business, though. Nothing personal.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Many patients have seen their long-term physicians retire. When I ask how they like their new doctors, they say: “She’s okay, I guess. Quite efficient. Seems thorough. But it’s not the same. It’s just business. Nothing personal.”

Sometimes you have to look backward to look forward. So it’s perhaps fitting that I glimpsed the future at my last colonoscopy.

In recent years, I’ve had such procedures at a local suburban surgicenter. Easy access, plenty of parking.

The woman who checks me in is all business. She scans my insurance cards and hands me a clipboard with a medical history form. Have I ever had cancer? A hernia? Am I pregnant? I wonder whether anyone reads these.

A different young woman brings me inside, the first of many new faces. Their roles are murky.

In a curtained cubby, yet another staff person asks me to pack my clothes in a plastic bag and put on a johnny. Then an older man enters, initiating furious multitasking. A different nursing assistant asks me to confirm my name and date of birth, then inserts an intravenous line in one arm, while the old doctor hands me an anesthesia consent form to sign with the other hand. I check many answers very fast, ignore the small-print boilerplate, and sign.

I am handed two more consent forms to sign, one from each side. The staff makes no pretense of explaining them or even telling me what they are for, and I make none of reading them.

They depart, replaced by still another person, who rolls me into the next room. He confirms my name and date of birth, and which procedure I am there for. The purpose of these multiple checks is clear, along with dispiriting depersonalization. One could mitigate this with some light banter, but no one bothers. No time.

My physician – whom I actually know – enters, says hello, and exchanges pleasantries. The last guy asks me to turn onto my left side. Intravenous sedation flows into my veins. The rest is silence.

Sometime later I wake up, greeted by another staff person. She asks if I am okay and offers me water or juice and saltines. Noting her Boston Red Sox sweatshirt, I say, “Great game last night,” but she does not know what I am talking about. She cares only for football and plans to fly to Nashville, Tenn., to watch her favorites.

Curtains are closed, and I am asked to dress. Another assistant directs me to a chair, where I will await my ride home. Through I try to walk alone, she takes my arm. “We assist everyone,” she explains.

As the sedation wears off, I observe. All around me I see movement, brisk and purposeful. Staff members crisscross before me from all angles, striding from one task to another, from prep room A to cubby D, walking with or pushing patients from procedure room M to holding area 8H. No one I’ve just met recognizes me, or acknowledges having met me before.

At last, the final staff member approaches. She flashes a kind smile as she takes my arm to walk me to the door. I take this for a personal touch, until she explains that she must make sure I don’t fall and that I get into the right car. As we pass, no one in the waiting room, neither staff nor patients, takes any notice.

My wife is outside, idling in the correct car. She’s brought coffee and a chocolate croissant, which – almost – makes last night’s prep worthwhile. She confirms neither my name nor date of birth.

Altogether, I have been in and out in 90 minutes. In the car, I peruse the handout that had been given to me as I exited. Drinking my coffee, I read the postcare instructions and enjoy its full-color pictures. Seldom has my cecum looked more radiant.

In “The Checklist Manifesto,” Atul Gawande described the outcome improvement that systematized practice can achieve. Data analysis confirms the measurably superior efficacy of such a method.

As for me, I feel like output from one of today’s cataract factories: like a car just extruded from an automated wash, with a photo on its front seat of the shiny, Simonized hubcaps included with the premium service package.

The medical care of the future? Okay, I guess. Seems efficient and thorough. Data confirm this.

Just business, though. Nothing personal.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Many patients have seen their long-term physicians retire. When I ask how they like their new doctors, they say: “She’s okay, I guess. Quite efficient. Seems thorough. But it’s not the same. It’s just business. Nothing personal.”

Sometimes you have to look backward to look forward. So it’s perhaps fitting that I glimpsed the future at my last colonoscopy.

In recent years, I’ve had such procedures at a local suburban surgicenter. Easy access, plenty of parking.

The woman who checks me in is all business. She scans my insurance cards and hands me a clipboard with a medical history form. Have I ever had cancer? A hernia? Am I pregnant? I wonder whether anyone reads these.

A different young woman brings me inside, the first of many new faces. Their roles are murky.

In a curtained cubby, yet another staff person asks me to pack my clothes in a plastic bag and put on a johnny. Then an older man enters, initiating furious multitasking. A different nursing assistant asks me to confirm my name and date of birth, then inserts an intravenous line in one arm, while the old doctor hands me an anesthesia consent form to sign with the other hand. I check many answers very fast, ignore the small-print boilerplate, and sign.

I am handed two more consent forms to sign, one from each side. The staff makes no pretense of explaining them or even telling me what they are for, and I make none of reading them.

They depart, replaced by still another person, who rolls me into the next room. He confirms my name and date of birth, and which procedure I am there for. The purpose of these multiple checks is clear, along with dispiriting depersonalization. One could mitigate this with some light banter, but no one bothers. No time.

My physician – whom I actually know – enters, says hello, and exchanges pleasantries. The last guy asks me to turn onto my left side. Intravenous sedation flows into my veins. The rest is silence.

Sometime later I wake up, greeted by another staff person. She asks if I am okay and offers me water or juice and saltines. Noting her Boston Red Sox sweatshirt, I say, “Great game last night,” but she does not know what I am talking about. She cares only for football and plans to fly to Nashville, Tenn., to watch her favorites.

Curtains are closed, and I am asked to dress. Another assistant directs me to a chair, where I will await my ride home. Through I try to walk alone, she takes my arm. “We assist everyone,” she explains.

As the sedation wears off, I observe. All around me I see movement, brisk and purposeful. Staff members crisscross before me from all angles, striding from one task to another, from prep room A to cubby D, walking with or pushing patients from procedure room M to holding area 8H. No one I’ve just met recognizes me, or acknowledges having met me before.

At last, the final staff member approaches. She flashes a kind smile as she takes my arm to walk me to the door. I take this for a personal touch, until she explains that she must make sure I don’t fall and that I get into the right car. As we pass, no one in the waiting room, neither staff nor patients, takes any notice.

My wife is outside, idling in the correct car. She’s brought coffee and a chocolate croissant, which – almost – makes last night’s prep worthwhile. She confirms neither my name nor date of birth.

Altogether, I have been in and out in 90 minutes. In the car, I peruse the handout that had been given to me as I exited. Drinking my coffee, I read the postcare instructions and enjoy its full-color pictures. Seldom has my cecum looked more radiant.

In “The Checklist Manifesto,” Atul Gawande described the outcome improvement that systematized practice can achieve. Data analysis confirms the measurably superior efficacy of such a method.

As for me, I feel like output from one of today’s cataract factories: like a car just extruded from an automated wash, with a photo on its front seat of the shiny, Simonized hubcaps included with the premium service package.

The medical care of the future? Okay, I guess. Seems efficient and thorough. Data confirm this.

Just business, though. Nothing personal.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Some people are civil; others are not. Some patients are polite, grateful, and courteous to a fault; others are angry, truculent, and aggressive. There may be reasons why such people are uncivil. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.

********

Charlie is 18. His mother is with him.

“I see my colleague prescribed an antibiotic for your acne.”

“No. I stopped the medicine after 2 weeks. It’s not acne.”

“Then what do you think it is?”

“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”

“Prednisone? That is not a good treatment for acne.”

“It’s not acne.”

“If that’s how you feel, then I think you will need to get another opinion.”

“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”

(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)

“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”

“Actually, no.”

“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.

“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.

Later that day Charlie calls back. He asks my secretary where he can post a bad review.

“Try our website,” suggests my staffer.

********

Gwen has many moles. Two were severely dysplastic and required re-excision.

“There is one mole on your back that I think needs to be tested.”

“Why?”

“Because it shows irregularity at the border.”

“I really hate surgery.”

“You may not need more surgery. We should find out, though.”

“I’m not saying you’re doing this just to get more money.”

“Well, thank you for that.”

“I’m not trying to be difficult.”

(But you are succeeding, aren’t you?)

“I also have warts on my finger.”

“I can freeze those for you.”

“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”

“Thank you. I will try to do it correctly.”

“I just want to advocate for myself.”

********

“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”

“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”

“Are all of you incompetent there? I told you my name, didn’t I?”

“Just once more, if you wouldn’t mind.”

“It’s Jomes, J-O-M-E-S. Have you got that?”

“Why, yes, and thank you for your patience. Your appointment is at 1:30.”

“It may rain.”

“Yes, so they say.”

“Well?”

“I’m sorry?”

“I asked you a question.”

“What question?”

“I asked you if it is going to rain.”

“I’m sorry Mr. Jomes. I just book appointments.”

Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.

But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.

I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”

Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Some people are civil; others are not. Some patients are polite, grateful, and courteous to a fault; others are angry, truculent, and aggressive. There may be reasons why such people are uncivil. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.

********

Charlie is 18. His mother is with him.

“I see my colleague prescribed an antibiotic for your acne.”

“No. I stopped the medicine after 2 weeks. It’s not acne.”

“Then what do you think it is?”

“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”

“Prednisone? That is not a good treatment for acne.”

“It’s not acne.”

“If that’s how you feel, then I think you will need to get another opinion.”

“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”

(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)

“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”

“Actually, no.”

“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.

“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.

Later that day Charlie calls back. He asks my secretary where he can post a bad review.

“Try our website,” suggests my staffer.

********

Gwen has many moles. Two were severely dysplastic and required re-excision.

“There is one mole on your back that I think needs to be tested.”

“Why?”

“Because it shows irregularity at the border.”

“I really hate surgery.”

“You may not need more surgery. We should find out, though.”

“I’m not saying you’re doing this just to get more money.”

“Well, thank you for that.”

“I’m not trying to be difficult.”

(But you are succeeding, aren’t you?)

“I also have warts on my finger.”

“I can freeze those for you.”

“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”

“Thank you. I will try to do it correctly.”

“I just want to advocate for myself.”

********

“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”

“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”

“Are all of you incompetent there? I told you my name, didn’t I?”

“Just once more, if you wouldn’t mind.”

“It’s Jomes, J-O-M-E-S. Have you got that?”

“Why, yes, and thank you for your patience. Your appointment is at 1:30.”

“It may rain.”

“Yes, so they say.”

“Well?”

“I’m sorry?”

“I asked you a question.”

“What question?”

“I asked you if it is going to rain.”

“I’m sorry Mr. Jomes. I just book appointments.”

Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.

But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.

I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”

Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Some people are civil; others are not. Some patients are polite, grateful, and courteous to a fault; others are angry, truculent, and aggressive. There may be reasons why such people are uncivil. Knowing those reasons does not make them any more civil than they aren’t, or any easier to take.

********

Charlie is 18. His mother is with him.

“I see my colleague prescribed an antibiotic for your acne.”

“No. I stopped the medicine after 2 weeks. It’s not acne.”

“Then what do you think it is?”

“Some sort of allergic reaction. I have a dog. I’ve taken two courses of prednisone.”

“Prednisone? That is not a good treatment for acne.”

“It’s not acne.”

“If that’s how you feel, then I think you will need to get another opinion.”

“My son can be difficult,” says his mother. “But just tell me – why do you think it’s acne?”

(Because I have been a skin doctor forever? Because Charlie is 18 and has pimples on his face?)

“If this were acne,” his mother goes on, “wouldn’t the pimples come in one place and go away in another?”

“Actually, no.”

“I don’t think I’ve ever been so offended,” says Charlie, who gets up and leaves.

“This is the most useless medical visit I have ever had,” says his mother. On the way out, she berates my secretary for working for such a worthless doctor.

Later that day Charlie calls back. He asks my secretary where he can post a bad review.

“Try our website,” suggests my staffer.

********

Gwen has many moles. Two were severely dysplastic and required re-excision.

“There is one mole on your back that I think needs to be tested.”

“Why?”

“Because it shows irregularity at the border.”

“I really hate surgery.”

“You may not need more surgery. We should find out, though.”

“I’m not saying you’re doing this just to get more money.”

“Well, thank you for that.”

“I’m not trying to be difficult.”

(But you are succeeding, aren’t you?)

“I also have warts on my finger.”

“I can freeze those for you.”

“Wait. Before you do, let me show you where to freeze. Put the nitrogen over here, where the wart is.”

“Thank you. I will try to do it correctly.”

“I just want to advocate for myself.”

********

“The emergency patient you worked in this morning is coming at 1:30,” says my secretary. “I couldn’t find his name in the system, so I called back.”

“Sorry sir, but I wanted to confirm your last name. It’s Jones, correct?”

“Are all of you incompetent there? I told you my name, didn’t I?”

“Just once more, if you wouldn’t mind.”

“It’s Jomes, J-O-M-E-S. Have you got that?”

“Why, yes, and thank you for your patience. Your appointment is at 1:30.”

“It may rain.”

“Yes, so they say.”

“Well?”

“I’m sorry?”

“I asked you a question.”

“What question?”

“I asked you if it is going to rain.”

“I’m sorry Mr. Jomes. I just book appointments.”

Amor Towles named his recent novel “Rules of Civility” after a note George Washington penned for his youthful self as a guide for getting along with people. Most of us intuit such rules just by noticing what works and what doesn’t, what pleases other people, or what makes them embarrassed or angry.

But there are people who don’t notice such things, or don’t care. They see nothing wrong with asking an old-time skin doctor how he knows that pimples are acne or demanding that he justify his opinion. (Or asking his staffer the best way to attack her boss.) They think it’s fine to suggest that a biopsy has been proposed for profit – after two prior biopsies arguably prevented severe disease – or making sure that a geezer with a spray can knows to put the nitrogen on the wart, not near it. Or berating a clerk for misspelling a last name of which he must have spent his life correcting other people’s misspellings.

I always taught students: “When people ask you how you know something, never invoke your experience or authority. If they don’t already think you have them, telling them you do won’t change their minds.”

Our job, often hard, is to always be civil. Society has zero tolerance for our ever being anything else. We know the rules. Uncivil people play by their own.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.

Those of us in the helping professions have fantasies, too, though fewer as times goes by. It gets harder even to daydream that we’ll make a rare diagnosis everyone missed or cure the condition no one could. But the temptation to dream, day or night, never quite goes away. ...

Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.

The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.

Pimecrolimus?!!!

I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.

Esteemed Director,

Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.

My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?

Cordially,

Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.

Curtis does not respond.

My staff calls three times. He doesn’t call back.

I write Curtis a letter. Nothing.

Maybe the Prior Authorization form chased away his eczema.

Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”

I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.

“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.

“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”

“There aren’t?”

“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”

“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”

In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!

A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”

Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.

What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.

Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.

I put my staff on it. Three hours later they find Courtney. In person. It’s all set!

I let Warren know. And then ...

Nothing.

Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.

No response.

My batting average with delusional parasitosis remains an immaculate 0.000.

Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.

And the patient needs to want to be rescued.

Not for nothing do they call them Rescue Fantasies.

Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. He had no disclosures relevant to this column. Write to him at [email protected].

In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.

Those of us in the helping professions have fantasies, too, though fewer as times goes by. It gets harder even to daydream that we’ll make a rare diagnosis everyone missed or cure the condition no one could. But the temptation to dream, day or night, never quite goes away. ...

Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.

The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.

Pimecrolimus?!!!

I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.

Esteemed Director,

Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.

My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?

Cordially,

Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.

Curtis does not respond.

My staff calls three times. He doesn’t call back.

I write Curtis a letter. Nothing.

Maybe the Prior Authorization form chased away his eczema.

Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”

I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.

“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.

“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”

“There aren’t?”

“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”

“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”

In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!

A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”

Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.

What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.

Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.

I put my staff on it. Three hours later they find Courtney. In person. It’s all set!

I let Warren know. And then ...

Nothing.

Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.

No response.

My batting average with delusional parasitosis remains an immaculate 0.000.

Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.

And the patient needs to want to be rescued.

Not for nothing do they call them Rescue Fantasies.

Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. He had no disclosures relevant to this column. Write to him at [email protected].

In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.

Those of us in the helping professions have fantasies, too, though fewer as times goes by. It gets harder even to daydream that we’ll make a rare diagnosis everyone missed or cure the condition no one could. But the temptation to dream, day or night, never quite goes away. ...

Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.

The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.

Pimecrolimus?!!!

I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.

Esteemed Director,

Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.

My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?

Cordially,

Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.

Curtis does not respond.

My staff calls three times. He doesn’t call back.

I write Curtis a letter. Nothing.

Maybe the Prior Authorization form chased away his eczema.

Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”

I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.

“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.

“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”

“There aren’t?”

“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”

“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”

In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!

A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”

Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.

What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.

Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.

I put my staff on it. Three hours later they find Courtney. In person. It’s all set!

I let Warren know. And then ...

Nothing.

Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.

No response.

My batting average with delusional parasitosis remains an immaculate 0.000.

Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.

And the patient needs to want to be rescued.

Not for nothing do they call them Rescue Fantasies.

Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. He had no disclosures relevant to this column. Write to him at [email protected].

In my practice, I have little use for evidence-based medicine.

Tero Vesalainen/iStock/Getty Images Plus

Of course I am not against evidence. I respect and value evidence. I just have little day-to-day use for it. Maybe your practices are different from mine, but I spend my working days seeing cases ...

Where evidence is irrelevant:

• there is nothing wrong but the patient thinks there might be (an itch, a burning sensation, a mole that may or may not have changed).
• the condition is self-limiting and needs no therapy (viral rashes).

Where evidence could help, but there isn’t any:

• there is no useful available treatment (age-related hair thinning in women).

Where evidence may be statistically significant but clinically trivial:

• pills that make herpes simplex cold sores go away in 6 days instead of 7, acne cream that reduces lesions by 70% instead of 40% (so that after 12 weeks the patient has five pimples instead of eight).

Where evidence is unimpressive or unconvincing (to the patient, who often stops treatment because “it wasn’t working” or “it made me worse”):

• the condition is recurrent, and the patient interprets recurrence as failure (eczema, psoriasis).
• the condition (psoriasis, eczema, acne ) moves around, and the patient interprets success (fewer spots) as failure. (“It’s come in a new place it never came before” or “I never used to get pimples on my jawline.”)
• slam-dunk clearances are few, and instead, every possible permutation in the condition’s course happens – persistence, recurrence, extension, spontaneous involution, going away in one place while proliferating in another, etc. (warts, alopecia areata).

Where patients find other kinds of evidence more compelling than mine:

• “I stopped your cream because calendula/tea tree oil/Vicks VapoRub/apple cider vinegar/avoiding gluten works better” (eczema, rosacea, onychomycosis, etc.). This dynamic is not limited to dermatology. How many Crohn’s patients have I met who say they left their conventional physicians with their standard treatments and now see a naturopath or acupuncturist? Their doctors don’t know they left, or why, because it’s impossible to remember someone who isn’t there, and their patients never told them why they left. These patients tell me they are now “doing better.”

Where evidence is outweighed by other patient considerations:

• topical 5-fluorouracil or imiquimod for superficial basal cells or noninvasive squamous cells in a patient who can’t reach the spot, doesn’t want to be bothered, or just wants the damned thing cut off.

Then, of course, there are cases where evidence is crucial. It’s just that, at the moment, I can’t think of many. Besides which, I’ve lost count of all the patients who had exhaustive food or patch testing, been found sensitive to any number of chemicals and foods – exotic or otherwise – dutifully avoided all of same, yet still break out intermittently and inscrutably, just like all my other atopics.

I’ve concluded that it must be me, or at least the small slice of the planet I work in. Maybe if I practice for 70 years instead of 40, or on five continents instead of the corner of just one, I will figure it all out.

To be clear: I am not a therapeutic nihilist. I want to use verifiably effective treatments for my patients, just as I wish such to be used on me when I need treatment. It’s just that instances in which compelling, decisive evidence makes a crucial difference don’t come up all that often. Evidence applies to populations, whereas I treat people, one at a time.

Meantime, I will muddle along, concerned that one drawback of the emphasis on “evidence” (i.e. statistics) not often noted is its contribution to depersonalizing medical practice, reducing the therapeutic interaction between two people to iterated instances of quantifiable throughput. If you can’t measure it, you didn’t do it and it doesn’t exist. But it does exist. Like every clinician, I see and do it every day.

As Hippocrates supposedly said: Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.

Evidence notwithstanding, judgment remains difficult, mine and the patient’s.

Now that I’m done with evidence, please stay tuned for future columns where I take on motherhood (unacceptably gendered!) and apple pie (fattening!)
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

In my practice, I have little use for evidence-based medicine.

Tero Vesalainen/iStock/Getty Images Plus

Of course I am not against evidence. I respect and value evidence. I just have little day-to-day use for it. Maybe your practices are different from mine, but I spend my working days seeing cases ...

Where evidence is irrelevant:

• there is nothing wrong but the patient thinks there might be (an itch, a burning sensation, a mole that may or may not have changed).
• the condition is self-limiting and needs no therapy (viral rashes).

Where evidence could help, but there isn’t any:

• there is no useful available treatment (age-related hair thinning in women).

Where evidence may be statistically significant but clinically trivial:

• pills that make herpes simplex cold sores go away in 6 days instead of 7, acne cream that reduces lesions by 70% instead of 40% (so that after 12 weeks the patient has five pimples instead of eight).

Where evidence is unimpressive or unconvincing (to the patient, who often stops treatment because “it wasn’t working” or “it made me worse”):

• the condition is recurrent, and the patient interprets recurrence as failure (eczema, psoriasis).
• the condition (psoriasis, eczema, acne ) moves around, and the patient interprets success (fewer spots) as failure. (“It’s come in a new place it never came before” or “I never used to get pimples on my jawline.”)
• slam-dunk clearances are few, and instead, every possible permutation in the condition’s course happens – persistence, recurrence, extension, spontaneous involution, going away in one place while proliferating in another, etc. (warts, alopecia areata).

Where patients find other kinds of evidence more compelling than mine:

• “I stopped your cream because calendula/tea tree oil/Vicks VapoRub/apple cider vinegar/avoiding gluten works better” (eczema, rosacea, onychomycosis, etc.). This dynamic is not limited to dermatology. How many Crohn’s patients have I met who say they left their conventional physicians with their standard treatments and now see a naturopath or acupuncturist? Their doctors don’t know they left, or why, because it’s impossible to remember someone who isn’t there, and their patients never told them why they left. These patients tell me they are now “doing better.”

Where evidence is outweighed by other patient considerations:

• topical 5-fluorouracil or imiquimod for superficial basal cells or noninvasive squamous cells in a patient who can’t reach the spot, doesn’t want to be bothered, or just wants the damned thing cut off.

Then, of course, there are cases where evidence is crucial. It’s just that, at the moment, I can’t think of many. Besides which, I’ve lost count of all the patients who had exhaustive food or patch testing, been found sensitive to any number of chemicals and foods – exotic or otherwise – dutifully avoided all of same, yet still break out intermittently and inscrutably, just like all my other atopics.

I’ve concluded that it must be me, or at least the small slice of the planet I work in. Maybe if I practice for 70 years instead of 40, or on five continents instead of the corner of just one, I will figure it all out.

To be clear: I am not a therapeutic nihilist. I want to use verifiably effective treatments for my patients, just as I wish such to be used on me when I need treatment. It’s just that instances in which compelling, decisive evidence makes a crucial difference don’t come up all that often. Evidence applies to populations, whereas I treat people, one at a time.

Meantime, I will muddle along, concerned that one drawback of the emphasis on “evidence” (i.e. statistics) not often noted is its contribution to depersonalizing medical practice, reducing the therapeutic interaction between two people to iterated instances of quantifiable throughput. If you can’t measure it, you didn’t do it and it doesn’t exist. But it does exist. Like every clinician, I see and do it every day.

As Hippocrates supposedly said: Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.

Evidence notwithstanding, judgment remains difficult, mine and the patient’s.

Now that I’m done with evidence, please stay tuned for future columns where I take on motherhood (unacceptably gendered!) and apple pie (fattening!)
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

In my practice, I have little use for evidence-based medicine.

Tero Vesalainen/iStock/Getty Images Plus

Of course I am not against evidence. I respect and value evidence. I just have little day-to-day use for it. Maybe your practices are different from mine, but I spend my working days seeing cases ...

Where evidence is irrelevant:

• there is nothing wrong but the patient thinks there might be (an itch, a burning sensation, a mole that may or may not have changed).
• the condition is self-limiting and needs no therapy (viral rashes).

Where evidence could help, but there isn’t any:

• there is no useful available treatment (age-related hair thinning in women).

Where evidence may be statistically significant but clinically trivial:

• pills that make herpes simplex cold sores go away in 6 days instead of 7, acne cream that reduces lesions by 70% instead of 40% (so that after 12 weeks the patient has five pimples instead of eight).

Where evidence is unimpressive or unconvincing (to the patient, who often stops treatment because “it wasn’t working” or “it made me worse”):

• the condition is recurrent, and the patient interprets recurrence as failure (eczema, psoriasis).
• the condition (psoriasis, eczema, acne ) moves around, and the patient interprets success (fewer spots) as failure. (“It’s come in a new place it never came before” or “I never used to get pimples on my jawline.”)
• slam-dunk clearances are few, and instead, every possible permutation in the condition’s course happens – persistence, recurrence, extension, spontaneous involution, going away in one place while proliferating in another, etc. (warts, alopecia areata).

Where patients find other kinds of evidence more compelling than mine:

• “I stopped your cream because calendula/tea tree oil/Vicks VapoRub/apple cider vinegar/avoiding gluten works better” (eczema, rosacea, onychomycosis, etc.). This dynamic is not limited to dermatology. How many Crohn’s patients have I met who say they left their conventional physicians with their standard treatments and now see a naturopath or acupuncturist? Their doctors don’t know they left, or why, because it’s impossible to remember someone who isn’t there, and their patients never told them why they left. These patients tell me they are now “doing better.”

Where evidence is outweighed by other patient considerations:

• topical 5-fluorouracil or imiquimod for superficial basal cells or noninvasive squamous cells in a patient who can’t reach the spot, doesn’t want to be bothered, or just wants the damned thing cut off.

Then, of course, there are cases where evidence is crucial. It’s just that, at the moment, I can’t think of many. Besides which, I’ve lost count of all the patients who had exhaustive food or patch testing, been found sensitive to any number of chemicals and foods – exotic or otherwise – dutifully avoided all of same, yet still break out intermittently and inscrutably, just like all my other atopics.

I’ve concluded that it must be me, or at least the small slice of the planet I work in. Maybe if I practice for 70 years instead of 40, or on five continents instead of the corner of just one, I will figure it all out.

To be clear: I am not a therapeutic nihilist. I want to use verifiably effective treatments for my patients, just as I wish such to be used on me when I need treatment. It’s just that instances in which compelling, decisive evidence makes a crucial difference don’t come up all that often. Evidence applies to populations, whereas I treat people, one at a time.

Meantime, I will muddle along, concerned that one drawback of the emphasis on “evidence” (i.e. statistics) not often noted is its contribution to depersonalizing medical practice, reducing the therapeutic interaction between two people to iterated instances of quantifiable throughput. If you can’t measure it, you didn’t do it and it doesn’t exist. But it does exist. Like every clinician, I see and do it every day.

As Hippocrates supposedly said: Life is short, and art long, opportunity fleeting, experimentations perilous, and judgment difficult.

Evidence notwithstanding, judgment remains difficult, mine and the patient’s.

Now that I’m done with evidence, please stay tuned for future columns where I take on motherhood (unacceptably gendered!) and apple pie (fattening!)
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.

kevron2001/Getty Images

Boris has a spot on his nose. I call with test results.

“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”

“Skin cancer?”

“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”

“Will I have to stay in the hospital?”

“No, it’s done under local anesthesia. You get it done and go home.”

“Is it urgent?”

“It can wait a few weeks. Just call for an appointment.”

“Will it be done in the hospital itself, or in another building?”

One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”

It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.

Stella is more perplexing than Boris, not to mention more challenging.

“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”

“Taken care of?”

“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”

“A healer?”

“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”

“With due respect, I don’t think she did.”

“Why do you say that?”

“Because it’s still there on your forehead. I can see it.”

Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.

The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.

I call Stella.

“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”

“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”

“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”

Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”

“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”

Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...

“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”

“Of course,” says Stella, “that goes without saying.”

“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”

We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.

kevron2001/Getty Images

Boris has a spot on his nose. I call with test results.

“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”

“Skin cancer?”

“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”

“Will I have to stay in the hospital?”

“No, it’s done under local anesthesia. You get it done and go home.”

“Is it urgent?”

“It can wait a few weeks. Just call for an appointment.”

“Will it be done in the hospital itself, or in another building?”

One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”

It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.

Stella is more perplexing than Boris, not to mention more challenging.

“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”

“Taken care of?”

“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”

“A healer?”

“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”

“With due respect, I don’t think she did.”

“Why do you say that?”

“Because it’s still there on your forehead. I can see it.”

Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.

The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.

I call Stella.

“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”

“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”

“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”

Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”

“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”

Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...

“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”

“Of course,” says Stella, “that goes without saying.”

“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”

We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Fear annoys. Fear mystifies. Fear masquerades. Fear can be trivial or terrifying. But fear is always there.

kevron2001/Getty Images

Boris has a spot on his nose. I call with test results.

“Boris, I got back your biopsy report. As expected, it did show a basal cell skin cancer.”

“Skin cancer?”

“Yes. As we discussed, basal cells are not serious and don’t spread, but you have to get it taken off.”

“Will I have to stay in the hospital?”

“No, it’s done under local anesthesia. You get it done and go home.”

“Is it urgent?”

“It can wait a few weeks. Just call for an appointment.”

“Will it be done in the hospital itself, or in another building?”

One question succeeds another. Each answer prompts another question. Sometimes the queries circle back and threaten to start the interrogation over. Children use the same tactic before you freeze their wart. “Wait! Will it hurt?” “Wait, wait, how many times will you freeze it?” “Wait, wait, how many seconds will it take?”

It takes patience, but Boris’s tone finally softens, and the questions stop. The queries are less requests for information than stalling tactics. Maybe if I keep asking, the problem will go away.

Stella is more perplexing than Boris, not to mention more challenging.

“I had a melanoma on my forehead, Doctor. But it’s all taken care of.”

“Taken care of?”

“Yes. The dermatologist in Clarksville did a biopsy, which showed melanoma, but I had a healer take care of it.”

“A healer?”

“Yes. I tell the healer my problem. She doesn’t even have to be there. She can heal from anywhere. She took care of it.”

“With due respect, I don’t think she did.”

“Why do you say that?”

“Because it’s still there on your forehead. I can see it.”

Stella and I negotiate. I will perform another biopsy, but only after she promises me that if the biopsy confirms the presence of melanoma, she’ll see a surgeon.

The biopsy shows melanoma in situ. Two weeks later the surgeon’s office calls to say that Stella has canceled her appointment.

I call Stella.

“I decided to cancel my appointment,” she says. “I asked the surgeon to perform another biopsy, but she refused. I found another dermatologist who will do it.”

“Just curious,” I say. “If two previous biopsies didn’t convince you that you have melanoma, why would a third?”

“Because I thought the healer had finished taking care of it, but she hadn’t,” Stella says. “Now she has.”

Stella pauses. “I know I’m on shaky ground here,” she says. “Maybe I don’t have a leg to stand on. But I just need to be sure.”

“You know,” I say, “if you don’t remove a melanoma, it can spread and cause death.”

Stella does know this. But she still isn’t sure it hasn’t already been taken care of. She has to be sure. Wait, wait ...

“You understand,” I say, “that I can’t be your doctor anymore, since you aren’t willing to follow my advice.”

“Of course,” says Stella, “that goes without saying.”

“Actually, it doesn’t,” I say. “If I can’t be responsible for your health, I have to make sure you know that, that you know why, and that you pick someone else to take care of you. It seems you have chosen someone.”

We all see many Borises. There are plenty of Stellas, too, though we don’t often see them. People who think as she does, who put their trust in strange treatments and sundry healers, don’t often show up in our offices. How they can think the way they do passes my understanding. But then much that I read or hear in the news about what people think passes my understanding. They are not my responsibility, though; Stella is, or at least she was.

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

When I stopped by last August to pick up new eyeglass lenses, Harold the optician sat alone in his shop.

“Business slow in the summer?” I asked.

Harold looked morose. “I knew it would be like this when I bought the business,” he said. “We’re open Saturdays, but summers I close at 2. Everybody’s at the Cape.”

Working in retail makes people more neurotic than necessary. I should know. I’ve been in retail for 40 years.

My patient Myrtle once explained to me how retail induces neurosis by deforming incentives. Myrtle used to work in management at a big department store. (Older readers may recall going to stores in buildings to buy things. The same readers may recall newspapers.)

“The month between Thanksgiving and Christmas makes or breaks the whole year,” Myrtle said. “If you do worse than last year, you feel bad. But if you do better than last year you also feel bad, because you worry you won’t be able to top it next year.”

She paused. “I guess that’s not a very healthy way to live, is it?”

I was too polite to agree.

Early in my career I had few patients on my schedule, maybe five on a good day. Then three of them would cancel. That was the start of my retail neurosis. Of course, I was a solo practitioner who started my own practice. The likes of me will someday be found in a museum, stuffed and mounted, along with other extinct species, under the label Medicus Cutaneous Solipsisticus (North America c. 20th century).

Over time, I got busier and dropped each of my eleven part-time jobs. By now I’ve been busy for decades, even though I’ve never had much of a waiting list. Don’t know why that is, but it no longer matters.

Except it does, psychologically. You won’t find this code in the DSM, but my working definition for the malady I describe is as follows:

Retail Neurosis (billable ICD-10 code F48.8. Other unspecified nonpsychotic mental disorders, along with writer’s block and psychasthenia):

Definition: The unquenchable fear that even the tiniest break in an endless churn of patients means that all patients will disappear later this afternoon, reverting the practice to the empty, formless void from whence it came. Other than retirement, there is no treatment for this disorder. And maybe not then either.

You might think to classify Retail Neurosis under Financial Insecurity, but that disorder has a different code. (F40.248, Fear of Failing, Life-Circumstance Problem). After all, a single well-remunerated patient (53 actinic keratoses!) can outreimburse half a dozen others with only E/M codes and big deductibles. Treat one of the former, take the rest of the hour off, and you’re financially just as well off, or even better. Yes?

No. Taking the rest of the hour off leaves you with too much time to ponder what every retailer knows: Each idle minute is another lost chance to make another sale and generate revenue. That minute (and revenue) can never be retrieved. Never!

As Myrtle would say, “Not a very healthy way to live, is it?”

Maybe not, but here as elsewhere, knowing something and fixing it are different things. Besides, brisk retail business brings a buzz, along with a sense of mastery and accomplishment, which is pleasantly addictive. Until it isn’t.

New generations of physicians and other medical providers will work in different settings than mine; they will be wage-earners in large organizations. These conglomerations bring their own neurosis-inducing incentives. Their managers measure providers’ productivity in various deforming and crazy-making ways. (See RVU-penia, ICD-10 M26.56: “Nonworking side interference.” This is actually a dental code that refers to jaw position, but billing demands creativity.) Practitioner anxieties will center on being docked for not generating enough relative value units or for failure to bundle enough comorbidities for maximizing capitation payments (e.g., Plaque Psoriasis plus Morbid Obesity plus Writer’s Block). But the youngsters will learn to get along. They’ll have to.

“Taking any time off this summer?” I asked my optician Harold.

“My wife and daughter are going out to Michigan in mid-August,” he said.

“Aren’t you going with them?”

“I can’t swing it that week,” he said. “By then, people are coming back to town, getting their kids ready for school. If I go away, I would miss some customers.”

Harold, you are my kind of guy!

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

When I stopped by last August to pick up new eyeglass lenses, Harold the optician sat alone in his shop.

“Business slow in the summer?” I asked.

Harold looked morose. “I knew it would be like this when I bought the business,” he said. “We’re open Saturdays, but summers I close at 2. Everybody’s at the Cape.”

Working in retail makes people more neurotic than necessary. I should know. I’ve been in retail for 40 years.

My patient Myrtle once explained to me how retail induces neurosis by deforming incentives. Myrtle used to work in management at a big department store. (Older readers may recall going to stores in buildings to buy things. The same readers may recall newspapers.)

“The month between Thanksgiving and Christmas makes or breaks the whole year,” Myrtle said. “If you do worse than last year, you feel bad. But if you do better than last year you also feel bad, because you worry you won’t be able to top it next year.”

She paused. “I guess that’s not a very healthy way to live, is it?”

I was too polite to agree.

Early in my career I had few patients on my schedule, maybe five on a good day. Then three of them would cancel. That was the start of my retail neurosis. Of course, I was a solo practitioner who started my own practice. The likes of me will someday be found in a museum, stuffed and mounted, along with other extinct species, under the label Medicus Cutaneous Solipsisticus (North America c. 20th century).

Over time, I got busier and dropped each of my eleven part-time jobs. By now I’ve been busy for decades, even though I’ve never had much of a waiting list. Don’t know why that is, but it no longer matters.

Except it does, psychologically. You won’t find this code in the DSM, but my working definition for the malady I describe is as follows:

Retail Neurosis (billable ICD-10 code F48.8. Other unspecified nonpsychotic mental disorders, along with writer’s block and psychasthenia):

Definition: The unquenchable fear that even the tiniest break in an endless churn of patients means that all patients will disappear later this afternoon, reverting the practice to the empty, formless void from whence it came. Other than retirement, there is no treatment for this disorder. And maybe not then either.

You might think to classify Retail Neurosis under Financial Insecurity, but that disorder has a different code. (F40.248, Fear of Failing, Life-Circumstance Problem). After all, a single well-remunerated patient (53 actinic keratoses!) can outreimburse half a dozen others with only E/M codes and big deductibles. Treat one of the former, take the rest of the hour off, and you’re financially just as well off, or even better. Yes?

No. Taking the rest of the hour off leaves you with too much time to ponder what every retailer knows: Each idle minute is another lost chance to make another sale and generate revenue. That minute (and revenue) can never be retrieved. Never!

As Myrtle would say, “Not a very healthy way to live, is it?”

Maybe not, but here as elsewhere, knowing something and fixing it are different things. Besides, brisk retail business brings a buzz, along with a sense of mastery and accomplishment, which is pleasantly addictive. Until it isn’t.

New generations of physicians and other medical providers will work in different settings than mine; they will be wage-earners in large organizations. These conglomerations bring their own neurosis-inducing incentives. Their managers measure providers’ productivity in various deforming and crazy-making ways. (See RVU-penia, ICD-10 M26.56: “Nonworking side interference.” This is actually a dental code that refers to jaw position, but billing demands creativity.) Practitioner anxieties will center on being docked for not generating enough relative value units or for failure to bundle enough comorbidities for maximizing capitation payments (e.g., Plaque Psoriasis plus Morbid Obesity plus Writer’s Block). But the youngsters will learn to get along. They’ll have to.

“Taking any time off this summer?” I asked my optician Harold.

“My wife and daughter are going out to Michigan in mid-August,” he said.

“Aren’t you going with them?”

“I can’t swing it that week,” he said. “By then, people are coming back to town, getting their kids ready for school. If I go away, I would miss some customers.”

Harold, you are my kind of guy!

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

When I stopped by last August to pick up new eyeglass lenses, Harold the optician sat alone in his shop.

“Business slow in the summer?” I asked.

Harold looked morose. “I knew it would be like this when I bought the business,” he said. “We’re open Saturdays, but summers I close at 2. Everybody’s at the Cape.”

Working in retail makes people more neurotic than necessary. I should know. I’ve been in retail for 40 years.

My patient Myrtle once explained to me how retail induces neurosis by deforming incentives. Myrtle used to work in management at a big department store. (Older readers may recall going to stores in buildings to buy things. The same readers may recall newspapers.)

“The month between Thanksgiving and Christmas makes or breaks the whole year,” Myrtle said. “If you do worse than last year, you feel bad. But if you do better than last year you also feel bad, because you worry you won’t be able to top it next year.”

She paused. “I guess that’s not a very healthy way to live, is it?”

I was too polite to agree.

Early in my career I had few patients on my schedule, maybe five on a good day. Then three of them would cancel. That was the start of my retail neurosis. Of course, I was a solo practitioner who started my own practice. The likes of me will someday be found in a museum, stuffed and mounted, along with other extinct species, under the label Medicus Cutaneous Solipsisticus (North America c. 20th century).

Over time, I got busier and dropped each of my eleven part-time jobs. By now I’ve been busy for decades, even though I’ve never had much of a waiting list. Don’t know why that is, but it no longer matters.

Except it does, psychologically. You won’t find this code in the DSM, but my working definition for the malady I describe is as follows:

Retail Neurosis (billable ICD-10 code F48.8. Other unspecified nonpsychotic mental disorders, along with writer’s block and psychasthenia):

Definition: The unquenchable fear that even the tiniest break in an endless churn of patients means that all patients will disappear later this afternoon, reverting the practice to the empty, formless void from whence it came. Other than retirement, there is no treatment for this disorder. And maybe not then either.

You might think to classify Retail Neurosis under Financial Insecurity, but that disorder has a different code. (F40.248, Fear of Failing, Life-Circumstance Problem). After all, a single well-remunerated patient (53 actinic keratoses!) can outreimburse half a dozen others with only E/M codes and big deductibles. Treat one of the former, take the rest of the hour off, and you’re financially just as well off, or even better. Yes?

No. Taking the rest of the hour off leaves you with too much time to ponder what every retailer knows: Each idle minute is another lost chance to make another sale and generate revenue. That minute (and revenue) can never be retrieved. Never!

As Myrtle would say, “Not a very healthy way to live, is it?”

Maybe not, but here as elsewhere, knowing something and fixing it are different things. Besides, brisk retail business brings a buzz, along with a sense of mastery and accomplishment, which is pleasantly addictive. Until it isn’t.

New generations of physicians and other medical providers will work in different settings than mine; they will be wage-earners in large organizations. These conglomerations bring their own neurosis-inducing incentives. Their managers measure providers’ productivity in various deforming and crazy-making ways. (See RVU-penia, ICD-10 M26.56: “Nonworking side interference.” This is actually a dental code that refers to jaw position, but billing demands creativity.) Practitioner anxieties will center on being docked for not generating enough relative value units or for failure to bundle enough comorbidities for maximizing capitation payments (e.g., Plaque Psoriasis plus Morbid Obesity plus Writer’s Block). But the youngsters will learn to get along. They’ll have to.

“Taking any time off this summer?” I asked my optician Harold.

“My wife and daughter are going out to Michigan in mid-August,” he said.

“Aren’t you going with them?”

“I can’t swing it that week,” he said. “By then, people are coming back to town, getting their kids ready for school. If I go away, I would miss some customers.”

Harold, you are my kind of guy!

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

On car trips with our kids, we used to listen to comedy tapes. (Cassette tapes. Look them up.) One of our favorite comics was Steven Wright, who made it to the Tonight Show with Johnny Carson. (Google him.)

Wright’s offbeat humor was quirky and a bit philosophical, and was delivered in a deadpan, mumbled monotone. For instance:

When I got to school, the teacher said, “The socks you’re wearing don’t match. They’re two different colors.”

I said, “I go by thickness.”

That punchline goes pop in your head, like a shy little firecracker: How come it never occurred to me to look at it that way?

I thought of Steven Wright recently while I was enrolling Stacy, a 20-year-old, in the iPledge program for a planned course of isotretinoin. Stacy told me she is sexually active and has an IUD.

“When you start the medicine next month,” I told her, “you’ll need to pick a second form of contraception.”

Stacy looked bewildered. When I’ve made that statement to a thousand previous patients, none of them ever looked bewildered.

“I mean,” I said, “besides the IUD, you’ll need to use a second type of contraception, to be sure you don’t get pregnant. You could choose condoms, or one of the other types listed in the booklet I gave you.”

That didn’t seem to help. Stacey hemmed a bit. “Does that mean I have to tell you ... ?”

“Yes, you have to pick another form of birth control and tell me which one it is.”

“I have to tell you every time?”

My go-by-thickness moment – I finally got it. “NO,” I said. “You do NOT have to tell me which second contraceptive you use every time you have sex!”

Steven Wright would be proud of Stacy. Isotretinoin came out in 1982, but nobody ever thought of “choose a second type of contraception” that way before. Stacy goes by retail.

That case reminded of another out-of-left field question I heard for the first – and only – time almost 40 years ago. I had prescribed a cream for a young man.

“Can I get it refilled?” he asked.

“Sure,” I said.

“How do I refill it?” he asked.

“You take it back to the pharmacy, and they refill it for you,” I said.

“But how do they refill it?”

“You show them what you need, and they refill it.”

“But how?”

“Why do you keep asking me that?”

“The tube is going to be all scrunched up from my squeezing it,” he said. “How do they get the new cream back in?”

Well son of a gun, “refill” could mean that, couldn’t it? If you go by thickness.

In idle moments I like to let novel perspectives such as those roll around in my head. The other day I accompanied a relative to an emergency department. While waiting in triage for 5 hours, I looked up and saw a sign on the wall, in big, blue letters: “Support ED Research!”

That puzzled me. I know it can be an important problem, but why the dickens would someone come to an emergency department for erectile dysfunction?

I go by acronyms.
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

On car trips with our kids, we used to listen to comedy tapes. (Cassette tapes. Look them up.) One of our favorite comics was Steven Wright, who made it to the Tonight Show with Johnny Carson. (Google him.)

Wright’s offbeat humor was quirky and a bit philosophical, and was delivered in a deadpan, mumbled monotone. For instance:

When I got to school, the teacher said, “The socks you’re wearing don’t match. They’re two different colors.”

I said, “I go by thickness.”

That punchline goes pop in your head, like a shy little firecracker: How come it never occurred to me to look at it that way?

I thought of Steven Wright recently while I was enrolling Stacy, a 20-year-old, in the iPledge program for a planned course of isotretinoin. Stacy told me she is sexually active and has an IUD.

“When you start the medicine next month,” I told her, “you’ll need to pick a second form of contraception.”

Stacy looked bewildered. When I’ve made that statement to a thousand previous patients, none of them ever looked bewildered.

“I mean,” I said, “besides the IUD, you’ll need to use a second type of contraception, to be sure you don’t get pregnant. You could choose condoms, or one of the other types listed in the booklet I gave you.”

That didn’t seem to help. Stacey hemmed a bit. “Does that mean I have to tell you ... ?”

“Yes, you have to pick another form of birth control and tell me which one it is.”

“I have to tell you every time?”

My go-by-thickness moment – I finally got it. “NO,” I said. “You do NOT have to tell me which second contraceptive you use every time you have sex!”

Steven Wright would be proud of Stacy. Isotretinoin came out in 1982, but nobody ever thought of “choose a second type of contraception” that way before. Stacy goes by retail.

That case reminded of another out-of-left field question I heard for the first – and only – time almost 40 years ago. I had prescribed a cream for a young man.

“Can I get it refilled?” he asked.

“Sure,” I said.

“How do I refill it?” he asked.

“You take it back to the pharmacy, and they refill it for you,” I said.

“But how do they refill it?”

“You show them what you need, and they refill it.”

“But how?”

“Why do you keep asking me that?”

“The tube is going to be all scrunched up from my squeezing it,” he said. “How do they get the new cream back in?”

Well son of a gun, “refill” could mean that, couldn’t it? If you go by thickness.

In idle moments I like to let novel perspectives such as those roll around in my head. The other day I accompanied a relative to an emergency department. While waiting in triage for 5 hours, I looked up and saw a sign on the wall, in big, blue letters: “Support ED Research!”

That puzzled me. I know it can be an important problem, but why the dickens would someone come to an emergency department for erectile dysfunction?

I go by acronyms.
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

On car trips with our kids, we used to listen to comedy tapes. (Cassette tapes. Look them up.) One of our favorite comics was Steven Wright, who made it to the Tonight Show with Johnny Carson. (Google him.)

Wright’s offbeat humor was quirky and a bit philosophical, and was delivered in a deadpan, mumbled monotone. For instance:

When I got to school, the teacher said, “The socks you’re wearing don’t match. They’re two different colors.”

I said, “I go by thickness.”

That punchline goes pop in your head, like a shy little firecracker: How come it never occurred to me to look at it that way?

I thought of Steven Wright recently while I was enrolling Stacy, a 20-year-old, in the iPledge program for a planned course of isotretinoin. Stacy told me she is sexually active and has an IUD.

“When you start the medicine next month,” I told her, “you’ll need to pick a second form of contraception.”

Stacy looked bewildered. When I’ve made that statement to a thousand previous patients, none of them ever looked bewildered.

“I mean,” I said, “besides the IUD, you’ll need to use a second type of contraception, to be sure you don’t get pregnant. You could choose condoms, or one of the other types listed in the booklet I gave you.”

That didn’t seem to help. Stacey hemmed a bit. “Does that mean I have to tell you ... ?”

“Yes, you have to pick another form of birth control and tell me which one it is.”

“I have to tell you every time?”

My go-by-thickness moment – I finally got it. “NO,” I said. “You do NOT have to tell me which second contraceptive you use every time you have sex!”

Steven Wright would be proud of Stacy. Isotretinoin came out in 1982, but nobody ever thought of “choose a second type of contraception” that way before. Stacy goes by retail.

That case reminded of another out-of-left field question I heard for the first – and only – time almost 40 years ago. I had prescribed a cream for a young man.

“Can I get it refilled?” he asked.

“Sure,” I said.

“How do I refill it?” he asked.

“You take it back to the pharmacy, and they refill it for you,” I said.

“But how do they refill it?”

“You show them what you need, and they refill it.”

“But how?”

“Why do you keep asking me that?”

“The tube is going to be all scrunched up from my squeezing it,” he said. “How do they get the new cream back in?”

Well son of a gun, “refill” could mean that, couldn’t it? If you go by thickness.

In idle moments I like to let novel perspectives such as those roll around in my head. The other day I accompanied a relative to an emergency department. While waiting in triage for 5 hours, I looked up and saw a sign on the wall, in big, blue letters: “Support ED Research!”

That puzzled me. I know it can be an important problem, but why the dickens would someone come to an emergency department for erectile dysfunction?

I go by acronyms.
 

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Octavio has prostate cancer. His prostate growth is large but localized.

“What do your doctors suggest?” I asked him.

“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”

“How will you decide?”

“I’ll do some reading,” he said.

“What about the doctor who sent you to them?”

“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”

Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:

Patient autonomy: The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.


This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:

1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”

2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”

Is “trying to influence” the same as making the decision for the patient?

Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.

Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?

FatCamera/Getty Images

You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.

Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?

Octavio chose surgery. I asked him how he decided.

“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”

Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.

You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.

“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Octavio has prostate cancer. His prostate growth is large but localized.

“What do your doctors suggest?” I asked him.

“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”

“How will you decide?”

“I’ll do some reading,” he said.

“What about the doctor who sent you to them?”

“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”

Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:

Patient autonomy: The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.


This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:

1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”

2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”

Is “trying to influence” the same as making the decision for the patient?

Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.

Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?

FatCamera/Getty Images

You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.

Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?

Octavio chose surgery. I asked him how he decided.

“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”

Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.

You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.

“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].

Octavio has prostate cancer. His prostate growth is large but localized.

“What do your doctors suggest?” I asked him.

“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”

“How will you decide?”

“I’ll do some reading,” he said.

“What about the doctor who sent you to them?”

“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”

Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:

Patient autonomy: The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.


This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:

1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”

2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”

Is “trying to influence” the same as making the decision for the patient?

Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.

Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?

FatCamera/Getty Images

You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.

Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?

Octavio chose surgery. I asked him how he decided.

“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”

Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.

You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.

“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”

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. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].