Under My Skin

Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.

I asked Doris about her overall medical condition.

“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)

“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.

“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.

The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.

“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”

“And that didn’t help?”

“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”

They didn’t look all that swollen to me.

“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”

You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.

Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.

How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.

This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.

Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.

I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.

Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.

Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.

Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.

I asked Doris about her overall medical condition.

“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)

“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.

“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.

The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.

“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”

“And that didn’t help?”

“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”

They didn’t look all that swollen to me.

“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”

You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.

Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.

How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.

This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.

Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.

I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.

Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.

Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.

Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.

I asked Doris about her overall medical condition.

“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)

“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.

“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.

The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.

“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”

“And that didn’t help?”

“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”

They didn’t look all that swollen to me.

“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”

You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.

Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.

How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.

This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.

Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.

I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.

Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.

Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.

In February I switched Kaleigh to adapalene because she said that tretinoin “was drying me out.” Yet, in June she’d stopped the adapalene “because it burned.”

“Did your face get red?” I asked.

“No, but it felt funny for a while after I put it on. So I went back to tretinoin.”

“But you said tretinoin dries you out.”

“It only does when the seasons change.”

Maybe you know what Kaleigh means. I don’t.

Patients often say they have “sensitive skin.” The traditional medical way to analyze this is physical: What conditions affect the cells, nerves, and blood vessels so skin looks and feels a certain way?

Another way to look at it is psychological: What about this person makes her or him pay attention to small changes in appearance or feeling?

I propose a third way: cultural. Whom does this person hang out with who experiences and describes sensations this way?

Aestheticians and patrons of skin care counters talk a lot about how their skin looks and feels in terms that sound strange in a medical context.

“I can’t use this moisturizer. It dries me out.”

Say what?

If patients on clindamycin lotion say it dries them out, I can protest in vain, “But it’s a moisturizer!” “It makes me feel dry,” they reply (or shiny or oily.) Saying this at the salon gets their money back, no questions asked, not just because it’s good business but because the aesthetician or clerk understands exactly what they mean and finds it quite reasonable.

I haven’t made a systematic study of cultural differences in the way people feel things on their skin. I just present several observations in the hope that someone might organize and make sense of them some day.

It’s known, for instance, that black patients may prefer moisturizers and hair pomades that a white patient would find too oily. Without moisturizing, black patients call their skin “ashy,” a word assumed to mean dry. It can’t be measured as dry, however, though it certainly feels that way to people who feel they have ashy skin.

The elderly often feel dry, too, though it’s far from established that they actually are: Wrinkling and itching don’t correlate with transepidermal water loss. From time immemorial, old age has been assumed to drain away vital body fluids. The elderly know they’re all dried out, so they feel that way.

The sexes differ too, in this as in so much else. Most women don’t feel right unless they’ve moisturized. (It wards off aging, they imagine.) Many men hate the feel of cream on their skin. Being of the male persuasion myself, I can testify that even the thought of applying sunscreen makes my flesh crawl; I have to grit my teeth to put it on.

I’m sure that, like me, you see long-married couples, where the wife says, “Look how dry he is, Doctor. Make him moisturize!” Hubby helplessly rolls his eyes. I mediate but do encourage him to eat his Cream of Wheat.

What do men and women “feel” that leads to their respective proclivities? I don’t know, but I’m pretty sure it won’t be found in the anatomy of sensory C fibers.

Likewise, I’m sure that you meet people with long-term rashes who are convinced they have “poison ivy” when they don’t. What makes them think so?

“It itches like poison ivy,” they insist. What does poison ivy itch like? I don’t know but they do, with great conviction. Somehow, not just appearances but sensations get diffused in the general culture. Something similar happens when patients diagnosed as not having zoster sigh with relief. “It burned just like shingles,” they say.

The other day I saw a woman with juicy, steroid-fed tinea corporis. “I’m sure it started as an insect bite,” she said. “How come?” I asked.

“It tingles,” she replied, “just like an insect bite.” Again, I don’t how an insect bite tingles, but she does.

Until someone explains all this, when one of my sensitive patients insists that the cream or pill I prescribed is drying them out or the moisturizer I suggested is “prunifying” them, I’ll just nod sagely and recommend something else that will, assuredly, not offend their sensitivities.

Usually works. I’m a sensitive guy.

In February I switched Kaleigh to adapalene because she said that tretinoin “was drying me out.” Yet, in June she’d stopped the adapalene “because it burned.”

“Did your face get red?” I asked.

“No, but it felt funny for a while after I put it on. So I went back to tretinoin.”

“But you said tretinoin dries you out.”

“It only does when the seasons change.”

Maybe you know what Kaleigh means. I don’t.

Patients often say they have “sensitive skin.” The traditional medical way to analyze this is physical: What conditions affect the cells, nerves, and blood vessels so skin looks and feels a certain way?

Another way to look at it is psychological: What about this person makes her or him pay attention to small changes in appearance or feeling?

I propose a third way: cultural. Whom does this person hang out with who experiences and describes sensations this way?

Aestheticians and patrons of skin care counters talk a lot about how their skin looks and feels in terms that sound strange in a medical context.

“I can’t use this moisturizer. It dries me out.”

Say what?

If patients on clindamycin lotion say it dries them out, I can protest in vain, “But it’s a moisturizer!” “It makes me feel dry,” they reply (or shiny or oily.) Saying this at the salon gets their money back, no questions asked, not just because it’s good business but because the aesthetician or clerk understands exactly what they mean and finds it quite reasonable.

I haven’t made a systematic study of cultural differences in the way people feel things on their skin. I just present several observations in the hope that someone might organize and make sense of them some day.

It’s known, for instance, that black patients may prefer moisturizers and hair pomades that a white patient would find too oily. Without moisturizing, black patients call their skin “ashy,” a word assumed to mean dry. It can’t be measured as dry, however, though it certainly feels that way to people who feel they have ashy skin.

The elderly often feel dry, too, though it’s far from established that they actually are: Wrinkling and itching don’t correlate with transepidermal water loss. From time immemorial, old age has been assumed to drain away vital body fluids. The elderly know they’re all dried out, so they feel that way.

The sexes differ too, in this as in so much else. Most women don’t feel right unless they’ve moisturized. (It wards off aging, they imagine.) Many men hate the feel of cream on their skin. Being of the male persuasion myself, I can testify that even the thought of applying sunscreen makes my flesh crawl; I have to grit my teeth to put it on.

I’m sure that, like me, you see long-married couples, where the wife says, “Look how dry he is, Doctor. Make him moisturize!” Hubby helplessly rolls his eyes. I mediate but do encourage him to eat his Cream of Wheat.

What do men and women “feel” that leads to their respective proclivities? I don’t know, but I’m pretty sure it won’t be found in the anatomy of sensory C fibers.

Likewise, I’m sure that you meet people with long-term rashes who are convinced they have “poison ivy” when they don’t. What makes them think so?

“It itches like poison ivy,” they insist. What does poison ivy itch like? I don’t know but they do, with great conviction. Somehow, not just appearances but sensations get diffused in the general culture. Something similar happens when patients diagnosed as not having zoster sigh with relief. “It burned just like shingles,” they say.

The other day I saw a woman with juicy, steroid-fed tinea corporis. “I’m sure it started as an insect bite,” she said. “How come?” I asked.

“It tingles,” she replied, “just like an insect bite.” Again, I don’t how an insect bite tingles, but she does.

Until someone explains all this, when one of my sensitive patients insists that the cream or pill I prescribed is drying them out or the moisturizer I suggested is “prunifying” them, I’ll just nod sagely and recommend something else that will, assuredly, not offend their sensitivities.

Usually works. I’m a sensitive guy.

In February I switched Kaleigh to adapalene because she said that tretinoin “was drying me out.” Yet, in June she’d stopped the adapalene “because it burned.”

“Did your face get red?” I asked.

“No, but it felt funny for a while after I put it on. So I went back to tretinoin.”

“But you said tretinoin dries you out.”

“It only does when the seasons change.”

Maybe you know what Kaleigh means. I don’t.

Patients often say they have “sensitive skin.” The traditional medical way to analyze this is physical: What conditions affect the cells, nerves, and blood vessels so skin looks and feels a certain way?

Another way to look at it is psychological: What about this person makes her or him pay attention to small changes in appearance or feeling?

I propose a third way: cultural. Whom does this person hang out with who experiences and describes sensations this way?

Aestheticians and patrons of skin care counters talk a lot about how their skin looks and feels in terms that sound strange in a medical context.

“I can’t use this moisturizer. It dries me out.”

Say what?

If patients on clindamycin lotion say it dries them out, I can protest in vain, “But it’s a moisturizer!” “It makes me feel dry,” they reply (or shiny or oily.) Saying this at the salon gets their money back, no questions asked, not just because it’s good business but because the aesthetician or clerk understands exactly what they mean and finds it quite reasonable.

I haven’t made a systematic study of cultural differences in the way people feel things on their skin. I just present several observations in the hope that someone might organize and make sense of them some day.

It’s known, for instance, that black patients may prefer moisturizers and hair pomades that a white patient would find too oily. Without moisturizing, black patients call their skin “ashy,” a word assumed to mean dry. It can’t be measured as dry, however, though it certainly feels that way to people who feel they have ashy skin.

The elderly often feel dry, too, though it’s far from established that they actually are: Wrinkling and itching don’t correlate with transepidermal water loss. From time immemorial, old age has been assumed to drain away vital body fluids. The elderly know they’re all dried out, so they feel that way.

The sexes differ too, in this as in so much else. Most women don’t feel right unless they’ve moisturized. (It wards off aging, they imagine.) Many men hate the feel of cream on their skin. Being of the male persuasion myself, I can testify that even the thought of applying sunscreen makes my flesh crawl; I have to grit my teeth to put it on.

I’m sure that, like me, you see long-married couples, where the wife says, “Look how dry he is, Doctor. Make him moisturize!” Hubby helplessly rolls his eyes. I mediate but do encourage him to eat his Cream of Wheat.

What do men and women “feel” that leads to their respective proclivities? I don’t know, but I’m pretty sure it won’t be found in the anatomy of sensory C fibers.

Likewise, I’m sure that you meet people with long-term rashes who are convinced they have “poison ivy” when they don’t. What makes them think so?

“It itches like poison ivy,” they insist. What does poison ivy itch like? I don’t know but they do, with great conviction. Somehow, not just appearances but sensations get diffused in the general culture. Something similar happens when patients diagnosed as not having zoster sigh with relief. “It burned just like shingles,” they say.

The other day I saw a woman with juicy, steroid-fed tinea corporis. “I’m sure it started as an insect bite,” she said. “How come?” I asked.

“It tingles,” she replied, “just like an insect bite.” Again, I don’t how an insect bite tingles, but she does.

Until someone explains all this, when one of my sensitive patients insists that the cream or pill I prescribed is drying them out or the moisturizer I suggested is “prunifying” them, I’ll just nod sagely and recommend something else that will, assuredly, not offend their sensitivities.

Usually works. I’m a sensitive guy.

We specialize in good news. You don't have a dread disease, we tell people. You aren't contagious or repulsive. That spot isn't cancer after all, and even if it is, we can take care of it. They shower us with thanks and praise.

But not this time.

I had seen Heather on Wednesday, a vibrant, self-confident young woman from Colorado with the milkiest, bone-white skin one could imagine. She spoke of summer research and plans for a career in science. She had a mole in her groin that was rubbing. I'd like to have it off before I go home, she said. Shave removal was quickly done.

Her biopsy report came to my desk at the end of Thursday. Melanoma, Clark level IV, almost 3 mm thick, with polypoid architecture.

Shock gave way to uncertainty. How to tell a young woman I hardly know troubling news for which she is totally unprepared? Certainly not on the phone.

I called her cell. Where are you? I asked. I was relieved to hear her say that she was just a few blocks from my office. Come over right now please, I said, I have to talk to you.

Ten minutes later, Heather sat in one of my exam rooms. A young man stood in the waiting area.

I faced her. I don't have good news, I said. The mole I took off yesterday turned out to be cancer.

Her eyes widened. What do you mean? she asked. What kind of cancer?
Melanoma, I said. It could be serious.

Heather started to weep. She said, but that doesn't make any sense! Skin cancer is from the sun. I haven't been in the sun. Ever! This can't possibly be true, she said. How can this be happening? Why is it happening to me? It isn't fair, it doesn't make sense!

I agreed, of course, but this was not the time to say so, to say anything at all. Heather wept with agitation. I joined her, but just a little, out of decorum.

After a while, we spoke of steps to take. She had to call her parents. I offered to assist.

It would be best to go home right away, I said, not wait for classes to end. She would need the cancer removed, staged. Further treatment might possibly be needed. Possibly! she cried, her voice heavy with sarcasm, fear turning to fury.

I invited her friend in to console her. Dad did not answer. I gave Heather my cell number, so he could reach me later. She and her friend embraced, alternating tears and laughter. Both soon left the office, our acquaintance intense but brief. I had barely met Heather, and won't be seeing her again.

That evening and much of the next morning were taken up with explanations to parents and calls to doctors in Heather's hometown. She arranged to leave school and schedule a prompt consultation with a surgical oncologist. Details are easier to confront than the enormity of what occasions them.

Why me? Why now? Every ill person asks these questions, but who can say? Is it my food, my behavior, my genes? Is it my fault?

Never mind, we say, let's just try to make you better. Though we rarely know the whys of things, it usually does not matter that much. But sometimes it does matter that much. Why should a young woman with her whole life before her be in mortal danger? As Heather saw at once, it isn't fair, it makes no sense.

No, it doesn't. But there is little to do besides attend to logistics and leave to other counselors the job of helping her confront what no one can explain.

We specialize in good news. You don't have a dread disease, we tell people. You aren't contagious or repulsive. That spot isn't cancer after all, and even if it is, we can take care of it. They shower us with thanks and praise.

But not this time.

I had seen Heather on Wednesday, a vibrant, self-confident young woman from Colorado with the milkiest, bone-white skin one could imagine. She spoke of summer research and plans for a career in science. She had a mole in her groin that was rubbing. I'd like to have it off before I go home, she said. Shave removal was quickly done.

Her biopsy report came to my desk at the end of Thursday. Melanoma, Clark level IV, almost 3 mm thick, with polypoid architecture.

Shock gave way to uncertainty. How to tell a young woman I hardly know troubling news for which she is totally unprepared? Certainly not on the phone.

I called her cell. Where are you? I asked. I was relieved to hear her say that she was just a few blocks from my office. Come over right now please, I said, I have to talk to you.

Ten minutes later, Heather sat in one of my exam rooms. A young man stood in the waiting area.

I faced her. I don't have good news, I said. The mole I took off yesterday turned out to be cancer.

Her eyes widened. What do you mean? she asked. What kind of cancer?
Melanoma, I said. It could be serious.

Heather started to weep. She said, but that doesn't make any sense! Skin cancer is from the sun. I haven't been in the sun. Ever! This can't possibly be true, she said. How can this be happening? Why is it happening to me? It isn't fair, it doesn't make sense!

I agreed, of course, but this was not the time to say so, to say anything at all. Heather wept with agitation. I joined her, but just a little, out of decorum.

After a while, we spoke of steps to take. She had to call her parents. I offered to assist.

It would be best to go home right away, I said, not wait for classes to end. She would need the cancer removed, staged. Further treatment might possibly be needed. Possibly! she cried, her voice heavy with sarcasm, fear turning to fury.

I invited her friend in to console her. Dad did not answer. I gave Heather my cell number, so he could reach me later. She and her friend embraced, alternating tears and laughter. Both soon left the office, our acquaintance intense but brief. I had barely met Heather, and won't be seeing her again.

That evening and much of the next morning were taken up with explanations to parents and calls to doctors in Heather's hometown. She arranged to leave school and schedule a prompt consultation with a surgical oncologist. Details are easier to confront than the enormity of what occasions them.

Why me? Why now? Every ill person asks these questions, but who can say? Is it my food, my behavior, my genes? Is it my fault?

Never mind, we say, let's just try to make you better. Though we rarely know the whys of things, it usually does not matter that much. But sometimes it does matter that much. Why should a young woman with her whole life before her be in mortal danger? As Heather saw at once, it isn't fair, it makes no sense.

No, it doesn't. But there is little to do besides attend to logistics and leave to other counselors the job of helping her confront what no one can explain.

We specialize in good news. You don't have a dread disease, we tell people. You aren't contagious or repulsive. That spot isn't cancer after all, and even if it is, we can take care of it. They shower us with thanks and praise.

But not this time.

I had seen Heather on Wednesday, a vibrant, self-confident young woman from Colorado with the milkiest, bone-white skin one could imagine. She spoke of summer research and plans for a career in science. She had a mole in her groin that was rubbing. I'd like to have it off before I go home, she said. Shave removal was quickly done.

Her biopsy report came to my desk at the end of Thursday. Melanoma, Clark level IV, almost 3 mm thick, with polypoid architecture.

Shock gave way to uncertainty. How to tell a young woman I hardly know troubling news for which she is totally unprepared? Certainly not on the phone.

I called her cell. Where are you? I asked. I was relieved to hear her say that she was just a few blocks from my office. Come over right now please, I said, I have to talk to you.

Ten minutes later, Heather sat in one of my exam rooms. A young man stood in the waiting area.

I faced her. I don't have good news, I said. The mole I took off yesterday turned out to be cancer.

Her eyes widened. What do you mean? she asked. What kind of cancer?
Melanoma, I said. It could be serious.

Heather started to weep. She said, but that doesn't make any sense! Skin cancer is from the sun. I haven't been in the sun. Ever! This can't possibly be true, she said. How can this be happening? Why is it happening to me? It isn't fair, it doesn't make sense!

I agreed, of course, but this was not the time to say so, to say anything at all. Heather wept with agitation. I joined her, but just a little, out of decorum.

After a while, we spoke of steps to take. She had to call her parents. I offered to assist.

It would be best to go home right away, I said, not wait for classes to end. She would need the cancer removed, staged. Further treatment might possibly be needed. Possibly! she cried, her voice heavy with sarcasm, fear turning to fury.

I invited her friend in to console her. Dad did not answer. I gave Heather my cell number, so he could reach me later. She and her friend embraced, alternating tears and laughter. Both soon left the office, our acquaintance intense but brief. I had barely met Heather, and won't be seeing her again.

That evening and much of the next morning were taken up with explanations to parents and calls to doctors in Heather's hometown. She arranged to leave school and schedule a prompt consultation with a surgical oncologist. Details are easier to confront than the enormity of what occasions them.

Why me? Why now? Every ill person asks these questions, but who can say? Is it my food, my behavior, my genes? Is it my fault?

Never mind, we say, let's just try to make you better. Though we rarely know the whys of things, it usually does not matter that much. But sometimes it does matter that much. Why should a young woman with her whole life before her be in mortal danger? As Heather saw at once, it isn't fair, it makes no sense.

No, it doesn't. But there is little to do besides attend to logistics and leave to other counselors the job of helping her confront what no one can explain.

For many years I've sent starry-eyed youths off to New York and Los Angeles to seek their fortune on Broadway or in Hollywood. I wish them luck, asking only that when they win their Tony or Oscar they remember who cleared up their skin. If their goal is to write, I ask that they pen a work starring a dermatologist.

I'm still waiting. Medicine has been fertile ground for many gripping movie and TV dramas, but these seem to center on emergency rooms, charismatic neurosurgeons, or internists with character disorders. Not a skin doctor in the bunch.

The only TV show that paid much attention to our specialty was "Seinfeld." Who can forget Jerry itching after shaving his chest hair; Jerry finding a tube of antifungal cream in his girlfriend's medicine chest; or Jerry deriding a dermatologist date as "Pimple Popper, M.D.," only to have an adjacent diner offer profound thanks for her lifesaving discovery of his melanoma?

So skin has had its moments. But no matter how we value our specialty's contribution to human happiness, we must acknowledge that the sometimes obsessive details of our daily work can play for laughs but not for pathos.

Nevertheless, I want to share the one episode in my career I can recall that did have real dramatic tension. If any reader wants to develop this incident into a TV pilot, have your people contact my people.

It happened this way: One day a friend called to say that 17-year-old Melvin was in the hospital with infections in both armpits. Oral antibiotics having failed, his physician admitted him for intravenous therapy, again with no results. The family suggested a dermatology consult, and the physician agreed. Would I come over?

Of course I would! I rarely visit hospitals anymore, but the opportunity to help out a family friend was welcome - especially since I was pretty sure I knew what he had and what to do about it. I expected no direct communication from the attending physician, and got none. I finished up at the office, drew up some Kenalog, packed alcohol pads and gauze, and headed over to the hospital.

There, I found Melvin flanked at the bedside by his anxious mother and a family friend. Both were married to physicians, raising the stakes. They explained the situation: Melvin had an infection so severe that even intravenous antibiotics had failed. What could be done?

I asked whether Melvin had ever had anything like this before. He had not. I examined him and found the expected.

I stood up and faced the family. In grave tones of reassurance and sagacity learned from reruns of "Masterpiece Theater," I said, "Melvin does not have an infection. He has hidradenitis suppurativa." This sounded more like an incantation than a diagnosis.

"Is that serious?" asked the mother.

"It can be easily treated," I explained. "In fact, I brought the treatment with me."

"But this must be a serious infection!" Melvin said. "Even IVs aren't helping."

"They aren't helping," I replied evenly, "not because you have a serious infection, but because you have no infection at all."

(Swelling violins. Cut to station break.)

After some further discussion, I convinced Melvin, his mother, and the friend that intralesional steroids were appropriate. I injected the swellings under each arm and promised to return the following day, departing to thanks tempered by anxiety. Could this exotic diagnosis with so many syllables be correct? Would the treatment actually work?

When I entered Melvin's room early the next morning, I was met with smiles of profound relief and heartfelt gratitude. The swelling was gone! The patient relieved! The unpronounceable presumption validated!

The transference in the room was thick enough to cut with a knife. I accepted the family's encomia with becoming modesty, of course, but couldn't resist the thought: How truly neat. Sure diagnosis and prompt success at the hospital bedside - by a dermatologist!

(Clashing cymbals. Cut to scenes from next week's episode.)

Well, maybe there won't be an episode next week. Though I still savor the unique circumstances of this small drama, I must admit that some medical specialties are just not cut out for prime time. But at least we're not alone.

Can you imagine "CSI: Miami, Forensic Urologists"?

Me neither.

For many years I've sent starry-eyed youths off to New York and Los Angeles to seek their fortune on Broadway or in Hollywood. I wish them luck, asking only that when they win their Tony or Oscar they remember who cleared up their skin. If their goal is to write, I ask that they pen a work starring a dermatologist.

I'm still waiting. Medicine has been fertile ground for many gripping movie and TV dramas, but these seem to center on emergency rooms, charismatic neurosurgeons, or internists with character disorders. Not a skin doctor in the bunch.

The only TV show that paid much attention to our specialty was "Seinfeld." Who can forget Jerry itching after shaving his chest hair; Jerry finding a tube of antifungal cream in his girlfriend's medicine chest; or Jerry deriding a dermatologist date as "Pimple Popper, M.D.," only to have an adjacent diner offer profound thanks for her lifesaving discovery of his melanoma?

So skin has had its moments. But no matter how we value our specialty's contribution to human happiness, we must acknowledge that the sometimes obsessive details of our daily work can play for laughs but not for pathos.

Nevertheless, I want to share the one episode in my career I can recall that did have real dramatic tension. If any reader wants to develop this incident into a TV pilot, have your people contact my people.

It happened this way: One day a friend called to say that 17-year-old Melvin was in the hospital with infections in both armpits. Oral antibiotics having failed, his physician admitted him for intravenous therapy, again with no results. The family suggested a dermatology consult, and the physician agreed. Would I come over?

Of course I would! I rarely visit hospitals anymore, but the opportunity to help out a family friend was welcome - especially since I was pretty sure I knew what he had and what to do about it. I expected no direct communication from the attending physician, and got none. I finished up at the office, drew up some Kenalog, packed alcohol pads and gauze, and headed over to the hospital.

There, I found Melvin flanked at the bedside by his anxious mother and a family friend. Both were married to physicians, raising the stakes. They explained the situation: Melvin had an infection so severe that even intravenous antibiotics had failed. What could be done?

I asked whether Melvin had ever had anything like this before. He had not. I examined him and found the expected.

I stood up and faced the family. In grave tones of reassurance and sagacity learned from reruns of "Masterpiece Theater," I said, "Melvin does not have an infection. He has hidradenitis suppurativa." This sounded more like an incantation than a diagnosis.

"Is that serious?" asked the mother.

"It can be easily treated," I explained. "In fact, I brought the treatment with me."

"But this must be a serious infection!" Melvin said. "Even IVs aren't helping."

"They aren't helping," I replied evenly, "not because you have a serious infection, but because you have no infection at all."

(Swelling violins. Cut to station break.)

After some further discussion, I convinced Melvin, his mother, and the friend that intralesional steroids were appropriate. I injected the swellings under each arm and promised to return the following day, departing to thanks tempered by anxiety. Could this exotic diagnosis with so many syllables be correct? Would the treatment actually work?

When I entered Melvin's room early the next morning, I was met with smiles of profound relief and heartfelt gratitude. The swelling was gone! The patient relieved! The unpronounceable presumption validated!

The transference in the room was thick enough to cut with a knife. I accepted the family's encomia with becoming modesty, of course, but couldn't resist the thought: How truly neat. Sure diagnosis and prompt success at the hospital bedside - by a dermatologist!

(Clashing cymbals. Cut to scenes from next week's episode.)

Well, maybe there won't be an episode next week. Though I still savor the unique circumstances of this small drama, I must admit that some medical specialties are just not cut out for prime time. But at least we're not alone.

Can you imagine "CSI: Miami, Forensic Urologists"?

Me neither.

For many years I've sent starry-eyed youths off to New York and Los Angeles to seek their fortune on Broadway or in Hollywood. I wish them luck, asking only that when they win their Tony or Oscar they remember who cleared up their skin. If their goal is to write, I ask that they pen a work starring a dermatologist.

I'm still waiting. Medicine has been fertile ground for many gripping movie and TV dramas, but these seem to center on emergency rooms, charismatic neurosurgeons, or internists with character disorders. Not a skin doctor in the bunch.

The only TV show that paid much attention to our specialty was "Seinfeld." Who can forget Jerry itching after shaving his chest hair; Jerry finding a tube of antifungal cream in his girlfriend's medicine chest; or Jerry deriding a dermatologist date as "Pimple Popper, M.D.," only to have an adjacent diner offer profound thanks for her lifesaving discovery of his melanoma?

So skin has had its moments. But no matter how we value our specialty's contribution to human happiness, we must acknowledge that the sometimes obsessive details of our daily work can play for laughs but not for pathos.

Nevertheless, I want to share the one episode in my career I can recall that did have real dramatic tension. If any reader wants to develop this incident into a TV pilot, have your people contact my people.

It happened this way: One day a friend called to say that 17-year-old Melvin was in the hospital with infections in both armpits. Oral antibiotics having failed, his physician admitted him for intravenous therapy, again with no results. The family suggested a dermatology consult, and the physician agreed. Would I come over?

Of course I would! I rarely visit hospitals anymore, but the opportunity to help out a family friend was welcome - especially since I was pretty sure I knew what he had and what to do about it. I expected no direct communication from the attending physician, and got none. I finished up at the office, drew up some Kenalog, packed alcohol pads and gauze, and headed over to the hospital.

There, I found Melvin flanked at the bedside by his anxious mother and a family friend. Both were married to physicians, raising the stakes. They explained the situation: Melvin had an infection so severe that even intravenous antibiotics had failed. What could be done?

I asked whether Melvin had ever had anything like this before. He had not. I examined him and found the expected.

I stood up and faced the family. In grave tones of reassurance and sagacity learned from reruns of "Masterpiece Theater," I said, "Melvin does not have an infection. He has hidradenitis suppurativa." This sounded more like an incantation than a diagnosis.

"Is that serious?" asked the mother.

"It can be easily treated," I explained. "In fact, I brought the treatment with me."

"But this must be a serious infection!" Melvin said. "Even IVs aren't helping."

"They aren't helping," I replied evenly, "not because you have a serious infection, but because you have no infection at all."

(Swelling violins. Cut to station break.)

After some further discussion, I convinced Melvin, his mother, and the friend that intralesional steroids were appropriate. I injected the swellings under each arm and promised to return the following day, departing to thanks tempered by anxiety. Could this exotic diagnosis with so many syllables be correct? Would the treatment actually work?

When I entered Melvin's room early the next morning, I was met with smiles of profound relief and heartfelt gratitude. The swelling was gone! The patient relieved! The unpronounceable presumption validated!

The transference in the room was thick enough to cut with a knife. I accepted the family's encomia with becoming modesty, of course, but couldn't resist the thought: How truly neat. Sure diagnosis and prompt success at the hospital bedside - by a dermatologist!

(Clashing cymbals. Cut to scenes from next week's episode.)

Well, maybe there won't be an episode next week. Though I still savor the unique circumstances of this small drama, I must admit that some medical specialties are just not cut out for prime time. But at least we're not alone.

Can you imagine "CSI: Miami, Forensic Urologists"?

Me neither.

"Doctor, thank you so much for seeing me on such short notice."

"When did you call for an appointment?"

"Two days ago."

"Sappho, in my office. Right now."

"What's the matter, Doctor?"

"My last patient called only 2 days ago and got an appointment."

"But you had an opening..."

"I know it, and you know it, but the whole world doesn't have to know it. What if my colleagues find out? When do we get Grisnelda's Mystery Shopper report?"

"At lunch, today."

"OK, Grisnelda, whenever you're ready."

"I made this quarter's calls to try getting appointments around town, Doctor."

"Excellent, Grisnelda. Did you use the untraceable cell phone?"

"Yes, and then I threw it in the Charles River just like they do in the Hudson on 'Law and Order.'"

"Great. What did you find?"

"Borromeo Dermatology has a 6-week wait, down from 7 last quarter. Birkenstock Integrative Cutaneous Wellness has 9 weeks, up from 8. Stanislavsky Skin is holding steady at 4 months."

"Stanislavsky only works Wednesday afternoons. What about the hospital clinics?"

"At Mount Saint Helen's they can see you in November."

"November of this year? By that time, you'll probably either be better or not care."

"And then of course there's UADLPSSCADLE."

"Who on earth is that?"

"That's the new name for Metroderm, the big group with offices all over. It stands for Urban Agglomeration for Dermatology, Laser, Plastic Surgery, Skin Care, Age Defiance, and Lifestyle Enhancement."

"Good heavens! How do they answer the phone?"

"'Urban Agglomeration - where, to whom, and toward what end may we direct your call?' They have a 3-month wait, and that's after dropping Medicaid and all the low-paying HMOs."

"We actually get some of their isotretinoin patients. They need to be confirmed on iPLEDGE once a month, but they can't fit them in for follow-up in less than two. Sappho, do you see how embarrassing this is? What kind of place must this practice be if you can be seen the day after tomorrow? Why would anybody want to get an appointment at a place where anybody can just call up and get an appointment?"

"But, Doctor..."

"Let me make this perfectly clear. If we let on that I have openings and the word gets out, then people will be unwilling to make appointments, and then I'll have openings. Do you follow?"

"Not exactly..."

"Well, thanks for your input, everybody. It's time for us to get back to work."

"Good afternoon, Mrs. Rabinowitz. My goodness, I haven't seen you in 4 years."

"I had a problem last summer, Doctor, but you were on vacation, and they told me I wouldn't be able to see you for 3 months."

"Three months! Mrs. Rabinowitz, in more than 30 years I have never had patients wait anywhere near that long. In fact..."

"Well, that's what the receptionist told me, Doctor. So I called another dermatologist down the street, and he took care of me the same day. Such a nice young man, too."

Dr. Rockoff writes the column, "Under My Skin," which regularly appears in Skin & Allergy News, an Elsevier publication. He practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at [email protected].

"Doctor, thank you so much for seeing me on such short notice."

"When did you call for an appointment?"

"Two days ago."

"Sappho, in my office. Right now."

"What's the matter, Doctor?"

"My last patient called only 2 days ago and got an appointment."

"But you had an opening..."

"I know it, and you know it, but the whole world doesn't have to know it. What if my colleagues find out? When do we get Grisnelda's Mystery Shopper report?"

"At lunch, today."

"OK, Grisnelda, whenever you're ready."

"I made this quarter's calls to try getting appointments around town, Doctor."

"Excellent, Grisnelda. Did you use the untraceable cell phone?"

"Yes, and then I threw it in the Charles River just like they do in the Hudson on 'Law and Order.'"

"Great. What did you find?"

"Borromeo Dermatology has a 6-week wait, down from 7 last quarter. Birkenstock Integrative Cutaneous Wellness has 9 weeks, up from 8. Stanislavsky Skin is holding steady at 4 months."

"Stanislavsky only works Wednesday afternoons. What about the hospital clinics?"

"At Mount Saint Helen's they can see you in November."

"November of this year? By that time, you'll probably either be better or not care."

"And then of course there's UADLPSSCADLE."

"Who on earth is that?"

"That's the new name for Metroderm, the big group with offices all over. It stands for Urban Agglomeration for Dermatology, Laser, Plastic Surgery, Skin Care, Age Defiance, and Lifestyle Enhancement."

"Good heavens! How do they answer the phone?"

"'Urban Agglomeration - where, to whom, and toward what end may we direct your call?' They have a 3-month wait, and that's after dropping Medicaid and all the low-paying HMOs."

"We actually get some of their isotretinoin patients. They need to be confirmed on iPLEDGE once a month, but they can't fit them in for follow-up in less than two. Sappho, do you see how embarrassing this is? What kind of place must this practice be if you can be seen the day after tomorrow? Why would anybody want to get an appointment at a place where anybody can just call up and get an appointment?"

"But, Doctor..."

"Let me make this perfectly clear. If we let on that I have openings and the word gets out, then people will be unwilling to make appointments, and then I'll have openings. Do you follow?"

"Not exactly..."

"Well, thanks for your input, everybody. It's time for us to get back to work."

"Good afternoon, Mrs. Rabinowitz. My goodness, I haven't seen you in 4 years."

"I had a problem last summer, Doctor, but you were on vacation, and they told me I wouldn't be able to see you for 3 months."

"Three months! Mrs. Rabinowitz, in more than 30 years I have never had patients wait anywhere near that long. In fact..."

"Well, that's what the receptionist told me, Doctor. So I called another dermatologist down the street, and he took care of me the same day. Such a nice young man, too."

Dr. Rockoff writes the column, "Under My Skin," which regularly appears in Skin & Allergy News, an Elsevier publication. He practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at [email protected].

"Doctor, thank you so much for seeing me on such short notice."

"When did you call for an appointment?"

"Two days ago."

"Sappho, in my office. Right now."

"What's the matter, Doctor?"

"My last patient called only 2 days ago and got an appointment."

"But you had an opening..."

"I know it, and you know it, but the whole world doesn't have to know it. What if my colleagues find out? When do we get Grisnelda's Mystery Shopper report?"

"At lunch, today."

"OK, Grisnelda, whenever you're ready."

"I made this quarter's calls to try getting appointments around town, Doctor."

"Excellent, Grisnelda. Did you use the untraceable cell phone?"

"Yes, and then I threw it in the Charles River just like they do in the Hudson on 'Law and Order.'"

"Great. What did you find?"

"Borromeo Dermatology has a 6-week wait, down from 7 last quarter. Birkenstock Integrative Cutaneous Wellness has 9 weeks, up from 8. Stanislavsky Skin is holding steady at 4 months."

"Stanislavsky only works Wednesday afternoons. What about the hospital clinics?"

"At Mount Saint Helen's they can see you in November."

"November of this year? By that time, you'll probably either be better or not care."

"And then of course there's UADLPSSCADLE."

"Who on earth is that?"

"That's the new name for Metroderm, the big group with offices all over. It stands for Urban Agglomeration for Dermatology, Laser, Plastic Surgery, Skin Care, Age Defiance, and Lifestyle Enhancement."

"Good heavens! How do they answer the phone?"

"'Urban Agglomeration - where, to whom, and toward what end may we direct your call?' They have a 3-month wait, and that's after dropping Medicaid and all the low-paying HMOs."

"We actually get some of their isotretinoin patients. They need to be confirmed on iPLEDGE once a month, but they can't fit them in for follow-up in less than two. Sappho, do you see how embarrassing this is? What kind of place must this practice be if you can be seen the day after tomorrow? Why would anybody want to get an appointment at a place where anybody can just call up and get an appointment?"

"But, Doctor..."

"Let me make this perfectly clear. If we let on that I have openings and the word gets out, then people will be unwilling to make appointments, and then I'll have openings. Do you follow?"

"Not exactly..."

"Well, thanks for your input, everybody. It's time for us to get back to work."

"Good afternoon, Mrs. Rabinowitz. My goodness, I haven't seen you in 4 years."

"I had a problem last summer, Doctor, but you were on vacation, and they told me I wouldn't be able to see you for 3 months."

"Three months! Mrs. Rabinowitz, in more than 30 years I have never had patients wait anywhere near that long. In fact..."

"Well, that's what the receptionist told me, Doctor. So I called another dermatologist down the street, and he took care of me the same day. Such a nice young man, too."

Dr. Rockoff writes the column, "Under My Skin," which regularly appears in Skin & Allergy News, an Elsevier publication. He practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at [email protected].

The man had an ordinary, American-sounding name. Let's call him Al Morse. Al lives in New Hampshire. It was midwinter when Al told me he was taking his wife dog sledding.

"Ever done the Iditarod?" I asked.
"Been to Alaska lots of times," he said. Then he added, "Thing is, my dogs only understand Ukrainian or Russian. You tell 'em 'Sit!' and they don't know what you're talking about. But say, 'Sydity!' and they sit right down.

"I learned how to talk to these dogs from my folks," said Al. "My people are from Dnepropetrovsk." He then launched into a series of (to me) flawlessly-accented Ukrainian sled-dog commands -- my favorite (though not in Ukrainian) being, "Show me your paw."

I doubt I'll ever ask a Slavic sled-dog to show me its paw, but knowing that Al does may give me insight if my team ever looks perplexed. Picking up tips like this helps me reflect on what a wonderful profession medicine can be. You meet people you'd never otherwise run into and find out about things they do that you never imagined existed, and couldn't make up.

Take Mr. Blanchard, a middle-aged gent not currently employed. He lives in Revere, Mass., just north of Boston. Mr. Blanchard, who has the kind of rolling baritone favored by earlier generations of radio announcers, has a deep love of two Old Testament books: Ecclesiastes and Job. That this pair is among the most depressing ever written does not dampen his enthusiasm for them. Mr. Blanchard said that he has committed to memory every available English translation of each. He will cite quotations at the drop of a hat, or even if a hat fails to drop.

Every morning at dawn Mr. Blanchard strides along Revere Beach and cries out the verses of Ecclesiastes and Job to the waves. This, he told me, does great things for his lungs and gets his day started out right, though what you would feel like doing with your day after digesting the wisdom of Job and Ecclesiastes is not clear. Perhaps having a doughnut?

"It's inspiring," said Mr. Blanchard, with gusto. "To look out over the waves and say, as Job did, 'All the rivers flow into the sea, yet the sea is not full.'"
That, I gently observed, was from Ecclesiastes. If you're going to limit your canon to two books, you might as well keep them straight.

I could not invent Mr. Blanchard. Yet I have met him.

And then, just the other day, Kevin came in with his mother. A wrestler, Kevin contracted a loathsome scalp infection that was now oozing south-by-southeast onto his forehead. Knowing how mothers often feel about their sons engaging in contact sports, I gibed, "How about taking up chess, Kevin?"

"I do chess boxing," he said, not missing a beat.
"What?"
"Chess boxing," he repeated. "It's really popular. First you make some chess moves, then you box, and you go back and forth. You win either by a checkmate or a knockout."
"What on Earth are you talking about?" I responded. I figured this kid for the slickest leg-puller I ever met, but he seemed quite sincere.

Later, I Googled "chess boxing," and wouldn't you know that it was right there on Wikipedia? (Where else?)

The article read: "Chess boxing is a hybrid sport which combines boxing with chess in alternating rounds. The sport began when Dutch artist Iepe Rubingh, inspired by fictional depictions by French comic book artist and filmmaker Enki Bilal, organized actual bouts. Chess boxing is now growing in popularity. Participants must be both skilled boxers and chess players, as a match may be won either way."

Are you going to tell me you didn't know about chess boxing? What do you do--spend all your time reading medical journals? You should get out more, or learn from your patients who do.

Ecclesiastes wrote that there is nothing new under the sun. I guess Ecclesiastes didn't know about chess boxing.


Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at our editorial offices at [email protected].

The man had an ordinary, American-sounding name. Let's call him Al Morse. Al lives in New Hampshire. It was midwinter when Al told me he was taking his wife dog sledding.

"Ever done the Iditarod?" I asked.
"Been to Alaska lots of times," he said. Then he added, "Thing is, my dogs only understand Ukrainian or Russian. You tell 'em 'Sit!' and they don't know what you're talking about. But say, 'Sydity!' and they sit right down.

"I learned how to talk to these dogs from my folks," said Al. "My people are from Dnepropetrovsk." He then launched into a series of (to me) flawlessly-accented Ukrainian sled-dog commands -- my favorite (though not in Ukrainian) being, "Show me your paw."

I doubt I'll ever ask a Slavic sled-dog to show me its paw, but knowing that Al does may give me insight if my team ever looks perplexed. Picking up tips like this helps me reflect on what a wonderful profession medicine can be. You meet people you'd never otherwise run into and find out about things they do that you never imagined existed, and couldn't make up.

Take Mr. Blanchard, a middle-aged gent not currently employed. He lives in Revere, Mass., just north of Boston. Mr. Blanchard, who has the kind of rolling baritone favored by earlier generations of radio announcers, has a deep love of two Old Testament books: Ecclesiastes and Job. That this pair is among the most depressing ever written does not dampen his enthusiasm for them. Mr. Blanchard said that he has committed to memory every available English translation of each. He will cite quotations at the drop of a hat, or even if a hat fails to drop.

Every morning at dawn Mr. Blanchard strides along Revere Beach and cries out the verses of Ecclesiastes and Job to the waves. This, he told me, does great things for his lungs and gets his day started out right, though what you would feel like doing with your day after digesting the wisdom of Job and Ecclesiastes is not clear. Perhaps having a doughnut?

"It's inspiring," said Mr. Blanchard, with gusto. "To look out over the waves and say, as Job did, 'All the rivers flow into the sea, yet the sea is not full.'"
That, I gently observed, was from Ecclesiastes. If you're going to limit your canon to two books, you might as well keep them straight.

I could not invent Mr. Blanchard. Yet I have met him.

And then, just the other day, Kevin came in with his mother. A wrestler, Kevin contracted a loathsome scalp infection that was now oozing south-by-southeast onto his forehead. Knowing how mothers often feel about their sons engaging in contact sports, I gibed, "How about taking up chess, Kevin?"

"I do chess boxing," he said, not missing a beat.
"What?"
"Chess boxing," he repeated. "It's really popular. First you make some chess moves, then you box, and you go back and forth. You win either by a checkmate or a knockout."
"What on Earth are you talking about?" I responded. I figured this kid for the slickest leg-puller I ever met, but he seemed quite sincere.

Later, I Googled "chess boxing," and wouldn't you know that it was right there on Wikipedia? (Where else?)

The article read: "Chess boxing is a hybrid sport which combines boxing with chess in alternating rounds. The sport began when Dutch artist Iepe Rubingh, inspired by fictional depictions by French comic book artist and filmmaker Enki Bilal, organized actual bouts. Chess boxing is now growing in popularity. Participants must be both skilled boxers and chess players, as a match may be won either way."

Are you going to tell me you didn't know about chess boxing? What do you do--spend all your time reading medical journals? You should get out more, or learn from your patients who do.

Ecclesiastes wrote that there is nothing new under the sun. I guess Ecclesiastes didn't know about chess boxing.


Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at our editorial offices at [email protected].

The man had an ordinary, American-sounding name. Let's call him Al Morse. Al lives in New Hampshire. It was midwinter when Al told me he was taking his wife dog sledding.

"Ever done the Iditarod?" I asked.
"Been to Alaska lots of times," he said. Then he added, "Thing is, my dogs only understand Ukrainian or Russian. You tell 'em 'Sit!' and they don't know what you're talking about. But say, 'Sydity!' and they sit right down.

"I learned how to talk to these dogs from my folks," said Al. "My people are from Dnepropetrovsk." He then launched into a series of (to me) flawlessly-accented Ukrainian sled-dog commands -- my favorite (though not in Ukrainian) being, "Show me your paw."

I doubt I'll ever ask a Slavic sled-dog to show me its paw, but knowing that Al does may give me insight if my team ever looks perplexed. Picking up tips like this helps me reflect on what a wonderful profession medicine can be. You meet people you'd never otherwise run into and find out about things they do that you never imagined existed, and couldn't make up.

Take Mr. Blanchard, a middle-aged gent not currently employed. He lives in Revere, Mass., just north of Boston. Mr. Blanchard, who has the kind of rolling baritone favored by earlier generations of radio announcers, has a deep love of two Old Testament books: Ecclesiastes and Job. That this pair is among the most depressing ever written does not dampen his enthusiasm for them. Mr. Blanchard said that he has committed to memory every available English translation of each. He will cite quotations at the drop of a hat, or even if a hat fails to drop.

Every morning at dawn Mr. Blanchard strides along Revere Beach and cries out the verses of Ecclesiastes and Job to the waves. This, he told me, does great things for his lungs and gets his day started out right, though what you would feel like doing with your day after digesting the wisdom of Job and Ecclesiastes is not clear. Perhaps having a doughnut?

"It's inspiring," said Mr. Blanchard, with gusto. "To look out over the waves and say, as Job did, 'All the rivers flow into the sea, yet the sea is not full.'"
That, I gently observed, was from Ecclesiastes. If you're going to limit your canon to two books, you might as well keep them straight.

I could not invent Mr. Blanchard. Yet I have met him.

And then, just the other day, Kevin came in with his mother. A wrestler, Kevin contracted a loathsome scalp infection that was now oozing south-by-southeast onto his forehead. Knowing how mothers often feel about their sons engaging in contact sports, I gibed, "How about taking up chess, Kevin?"

"I do chess boxing," he said, not missing a beat.
"What?"
"Chess boxing," he repeated. "It's really popular. First you make some chess moves, then you box, and you go back and forth. You win either by a checkmate or a knockout."
"What on Earth are you talking about?" I responded. I figured this kid for the slickest leg-puller I ever met, but he seemed quite sincere.

Later, I Googled "chess boxing," and wouldn't you know that it was right there on Wikipedia? (Where else?)

The article read: "Chess boxing is a hybrid sport which combines boxing with chess in alternating rounds. The sport began when Dutch artist Iepe Rubingh, inspired by fictional depictions by French comic book artist and filmmaker Enki Bilal, organized actual bouts. Chess boxing is now growing in popularity. Participants must be both skilled boxers and chess players, as a match may be won either way."

Are you going to tell me you didn't know about chess boxing? What do you do--spend all your time reading medical journals? You should get out more, or learn from your patients who do.

Ecclesiastes wrote that there is nothing new under the sun. I guess Ecclesiastes didn't know about chess boxing.


Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at our editorial offices at [email protected].

Irma had a few spots on her face. I told her I could freeze them off.

"This may not be a good time," she said. "I'm going to a professional convention this weekend, and I don't want to be self-conscious."

"That's fine," I said. "In that case, maybe when you have vacation."

"No, any other week will be fine."

"But won't your patients notice?"

"Probably not," she said. "They're too self-absorbed."

Irma is a psychologist.

Her observation is striking, because it contrasts so strongly with what most people say about the reactions they get when there is something noticeable on their faces. Irma may think her patients will be indifferent, but teachers and relatives of small children expect the opposite. Children don't know much about tact.

"What is that ugly thing on your chin Mrs. Donnelly!?" the kids yell. Grandparents tell similar stories about their little darlings. That's when they decide to get the growth taken off, the one they've had for decades.

All of us have a very strong urge to point out blemishes, especially on the face--a red mark, a piece of food hanging off our dining partner's lower lip. Not noticing takes an awful lot of self-absorption.

But some people rise to the self-absorptive occasion in other ways. For instance, one of my colleagues collaborates with a plastic surgeon based in his office 2 days a week. The surgeon developed acute abdominal pain one night and was rushed to a local emergency room. When a CT scan showed appendicitis, he was taken to the operating room first thing in the morning. My friend's secretary started calling the surgeon's patients to let them know that their consultations or surgeries would have to be postponed.

Most people reacted with appropriate concern - "Oh, I'm so sorry to hear that! How is he doing?" and so on - but not everyone.

"I'm sorry to tell you that Dr. Jenkins won't be able to see you today. He's having emergency surgery himself."

"Oh. I see. That's very disappointing."

"Of course. But we'll let you know as soon we find out when he's coming back to work."

"This is very disappointing."

Alas, so it is.

Another patient had flown up from Florida for a second opinion about biopsy-proved skin cancer. When the second opinion was the same as the first - that the cancer be removed - an expedited consultation was arranged with the surgeon so the Floridian could go right back to the sun. When appendicitis struck the surgeon, the patient was apprised of the situation.

"But when will Dr. Jenkins be able to operate?" he wanted to know.

"He's in surgery himself right now," he was told. "We hope he recovers fast, but at this point we really can't tell you."

"But I have to make plans," he said. "When will he be able to take care of my problem?"

What the secretary thought of saying, but didn't, was this: "Tell you what. We'll camp out in the recovery room with a phone next to Dr. Jenkins' lips. The second his anesthesia wears off, we're sure his very first words - after he asks about his mistress - will be to tell us when he can operate on you."

Talk about self-absorption.

Of course, we meet self-absorbed people in all walks of life. And all of us - even doctors! - are entitled to think about our own pressures and problems, though sharing them with patients is generally not a good move. ("You think you've got a rash? Have a look at mine!") It's okay to be annoyed when your doctor, lawyer, or accountant can't see you as scheduled, but most people older than a certain age can see the larger context and stifle the urge to express our annoyance.

I saw Irma again after her convention and froze her offending spots. "I guess from what you said," I said, "your self-absorbed patients won't even notice."

"I'm not sure my colleagues would have, either," she said with a wry smile. "They're psychologists."

Irma had a few spots on her face. I told her I could freeze them off.

"This may not be a good time," she said. "I'm going to a professional convention this weekend, and I don't want to be self-conscious."

"That's fine," I said. "In that case, maybe when you have vacation."

"No, any other week will be fine."

"But won't your patients notice?"

"Probably not," she said. "They're too self-absorbed."

Irma is a psychologist.

Her observation is striking, because it contrasts so strongly with what most people say about the reactions they get when there is something noticeable on their faces. Irma may think her patients will be indifferent, but teachers and relatives of small children expect the opposite. Children don't know much about tact.

"What is that ugly thing on your chin Mrs. Donnelly!?" the kids yell. Grandparents tell similar stories about their little darlings. That's when they decide to get the growth taken off, the one they've had for decades.

All of us have a very strong urge to point out blemishes, especially on the face--a red mark, a piece of food hanging off our dining partner's lower lip. Not noticing takes an awful lot of self-absorption.

But some people rise to the self-absorptive occasion in other ways. For instance, one of my colleagues collaborates with a plastic surgeon based in his office 2 days a week. The surgeon developed acute abdominal pain one night and was rushed to a local emergency room. When a CT scan showed appendicitis, he was taken to the operating room first thing in the morning. My friend's secretary started calling the surgeon's patients to let them know that their consultations or surgeries would have to be postponed.

Most people reacted with appropriate concern - "Oh, I'm so sorry to hear that! How is he doing?" and so on - but not everyone.

"I'm sorry to tell you that Dr. Jenkins won't be able to see you today. He's having emergency surgery himself."

"Oh. I see. That's very disappointing."

"Of course. But we'll let you know as soon we find out when he's coming back to work."

"This is very disappointing."

Alas, so it is.

Another patient had flown up from Florida for a second opinion about biopsy-proved skin cancer. When the second opinion was the same as the first - that the cancer be removed - an expedited consultation was arranged with the surgeon so the Floridian could go right back to the sun. When appendicitis struck the surgeon, the patient was apprised of the situation.

"But when will Dr. Jenkins be able to operate?" he wanted to know.

"He's in surgery himself right now," he was told. "We hope he recovers fast, but at this point we really can't tell you."

"But I have to make plans," he said. "When will he be able to take care of my problem?"

What the secretary thought of saying, but didn't, was this: "Tell you what. We'll camp out in the recovery room with a phone next to Dr. Jenkins' lips. The second his anesthesia wears off, we're sure his very first words - after he asks about his mistress - will be to tell us when he can operate on you."

Talk about self-absorption.

Of course, we meet self-absorbed people in all walks of life. And all of us - even doctors! - are entitled to think about our own pressures and problems, though sharing them with patients is generally not a good move. ("You think you've got a rash? Have a look at mine!") It's okay to be annoyed when your doctor, lawyer, or accountant can't see you as scheduled, but most people older than a certain age can see the larger context and stifle the urge to express our annoyance.

I saw Irma again after her convention and froze her offending spots. "I guess from what you said," I said, "your self-absorbed patients won't even notice."

"I'm not sure my colleagues would have, either," she said with a wry smile. "They're psychologists."

Irma had a few spots on her face. I told her I could freeze them off.

"This may not be a good time," she said. "I'm going to a professional convention this weekend, and I don't want to be self-conscious."

"That's fine," I said. "In that case, maybe when you have vacation."

"No, any other week will be fine."

"But won't your patients notice?"

"Probably not," she said. "They're too self-absorbed."

Irma is a psychologist.

Her observation is striking, because it contrasts so strongly with what most people say about the reactions they get when there is something noticeable on their faces. Irma may think her patients will be indifferent, but teachers and relatives of small children expect the opposite. Children don't know much about tact.

"What is that ugly thing on your chin Mrs. Donnelly!?" the kids yell. Grandparents tell similar stories about their little darlings. That's when they decide to get the growth taken off, the one they've had for decades.

All of us have a very strong urge to point out blemishes, especially on the face--a red mark, a piece of food hanging off our dining partner's lower lip. Not noticing takes an awful lot of self-absorption.

But some people rise to the self-absorptive occasion in other ways. For instance, one of my colleagues collaborates with a plastic surgeon based in his office 2 days a week. The surgeon developed acute abdominal pain one night and was rushed to a local emergency room. When a CT scan showed appendicitis, he was taken to the operating room first thing in the morning. My friend's secretary started calling the surgeon's patients to let them know that their consultations or surgeries would have to be postponed.

Most people reacted with appropriate concern - "Oh, I'm so sorry to hear that! How is he doing?" and so on - but not everyone.

"I'm sorry to tell you that Dr. Jenkins won't be able to see you today. He's having emergency surgery himself."

"Oh. I see. That's very disappointing."

"Of course. But we'll let you know as soon we find out when he's coming back to work."

"This is very disappointing."

Alas, so it is.

Another patient had flown up from Florida for a second opinion about biopsy-proved skin cancer. When the second opinion was the same as the first - that the cancer be removed - an expedited consultation was arranged with the surgeon so the Floridian could go right back to the sun. When appendicitis struck the surgeon, the patient was apprised of the situation.

"But when will Dr. Jenkins be able to operate?" he wanted to know.

"He's in surgery himself right now," he was told. "We hope he recovers fast, but at this point we really can't tell you."

"But I have to make plans," he said. "When will he be able to take care of my problem?"

What the secretary thought of saying, but didn't, was this: "Tell you what. We'll camp out in the recovery room with a phone next to Dr. Jenkins' lips. The second his anesthesia wears off, we're sure his very first words - after he asks about his mistress - will be to tell us when he can operate on you."

Talk about self-absorption.

Of course, we meet self-absorbed people in all walks of life. And all of us - even doctors! - are entitled to think about our own pressures and problems, though sharing them with patients is generally not a good move. ("You think you've got a rash? Have a look at mine!") It's okay to be annoyed when your doctor, lawyer, or accountant can't see you as scheduled, but most people older than a certain age can see the larger context and stifle the urge to express our annoyance.

I saw Irma again after her convention and froze her offending spots. "I guess from what you said," I said, "your self-absorbed patients won't even notice."

"I'm not sure my colleagues would have, either," she said with a wry smile. "They're psychologists."

I was in a most undignified position: lying on a gurney in a curtained cubicle, wearing a johnny under a flimsy sheet, awaiting my 5-year colonoscopy and feeling, well, washed out. That's when I overheard a doctor's voice from the next cubicle.

"Everything looked fine, Mrs. Jenkins," said the voice. "Just some small external hemorrhoids. You might consider drinking a lot of water and eating a fiber-rich diet."

Although I'm no gastroenterologist, I know it when I hear it: verbal boilerplate. I even know it when I say it, though I try not to.

Boilerplate language is a Victorian-age metaphor. From steel sheets that could be used over and over in different machines without change came the idea of reusable units of writing – no thought needed.

We all use verbal boilerplates every day, in and out of the office. ("How's everything?" "Fine. "What's happening?" "Not much.") Verbal boilerplate has two qualities: it's delivered without much inflection, and it doesn't convey a lot of information. Of course, the second quality can be helpful. You don't really want to know how everything is, do you?

But in a professional context, boilerplate has drawbacks. The way it's delivered signals what's really going on. That's how, chilly and distracted though I was, I sensed I was hearing verbal boilerplate even before the words registered. The delivery was quieter, faster, flatter. Hemorrhoids? Press mental button: lots-of-water-fiber-rich-diet.

The second aspect, not unrelated, is that verbal boilerplate is technically correct but doesn't say much. How much water is "lots?" How much fiber is "fiber-rich?" What kind of fiber? How often?

Maybe it doesn't really matter, but that's exactly the point: when you communicate with verbal boilerplate, what you're really saying is, "I'm telling you something I'm supposed to, but whether you understand or follow my advice isn't all that important."

Such communication presents problems. The first, from a medical standpoint, is that signaling that a piece of advice isn't crucial doesn't exactly promote adherence. (Reading compliance studies is always depressing anyway.) The second, from an ordinary human perspective, is that it's deflating to ask a serious personal question – which is how patients tend to think of their concerns – and get what is in effect a canned response.

We don't like to think we dispense boilerplate, but it can be hard not to. When we see a new acne patient, how many novel and creative ways are there to present the basic spiel: no, it's not food; yes, you can use makeup; please don't pick your pimples; apply the creams and take your pills regularly; don't be discouraged if you don't clear up in 2 weeks; and, as Jerry Seinfeld might add, "Yadda yadda yadda."

The same is true for eczema, warts, or any of the routine things any dermatologist deals with daily. How tempting is it to succumb and dispense boilerplate? You've got disease X? Here is response Y. Gotta go now.

But avoiding this is indeed possible without a lot of effort or time. The first step is to recognize the problem and listen to ourselves as though we're the patient. The second is to vary the mode of presentation, even if just a bit, between one visit and the next (changing sentence order, modifying phrasing.) The third is to add emphasis to show we're making a point we really want to put across and that it does matter whether the patient understands the instructions and knows how to follow the directions. The fourth is to maintain eye contact and vary inflection to show that we are not, in fact, automated attendants giving recorded announcements with implied or explicit disclaimers, that the opinions herein expressed are not those of the management, the medical society, or the Department of Homeland Security.

Written boilerplate in a contract or lease agreement has lots of words in tiny print to show that you don't have to spend time reading it. Verbal boilerplate sends a similar message: careful listening isn't required. In that case, why bother saying it?

A week after my gurney epiphany, I got a letter from the gastroenterologist telling me I don't need another colonoscopy for 5 years. Now that's what I call meaningful communication.

I was in a most undignified position: lying on a gurney in a curtained cubicle, wearing a johnny under a flimsy sheet, awaiting my 5-year colonoscopy and feeling, well, washed out. That's when I overheard a doctor's voice from the next cubicle.

"Everything looked fine, Mrs. Jenkins," said the voice. "Just some small external hemorrhoids. You might consider drinking a lot of water and eating a fiber-rich diet."

Although I'm no gastroenterologist, I know it when I hear it: verbal boilerplate. I even know it when I say it, though I try not to.

Boilerplate language is a Victorian-age metaphor. From steel sheets that could be used over and over in different machines without change came the idea of reusable units of writing – no thought needed.

We all use verbal boilerplates every day, in and out of the office. ("How's everything?" "Fine. "What's happening?" "Not much.") Verbal boilerplate has two qualities: it's delivered without much inflection, and it doesn't convey a lot of information. Of course, the second quality can be helpful. You don't really want to know how everything is, do you?

But in a professional context, boilerplate has drawbacks. The way it's delivered signals what's really going on. That's how, chilly and distracted though I was, I sensed I was hearing verbal boilerplate even before the words registered. The delivery was quieter, faster, flatter. Hemorrhoids? Press mental button: lots-of-water-fiber-rich-diet.

The second aspect, not unrelated, is that verbal boilerplate is technically correct but doesn't say much. How much water is "lots?" How much fiber is "fiber-rich?" What kind of fiber? How often?

Maybe it doesn't really matter, but that's exactly the point: when you communicate with verbal boilerplate, what you're really saying is, "I'm telling you something I'm supposed to, but whether you understand or follow my advice isn't all that important."

Such communication presents problems. The first, from a medical standpoint, is that signaling that a piece of advice isn't crucial doesn't exactly promote adherence. (Reading compliance studies is always depressing anyway.) The second, from an ordinary human perspective, is that it's deflating to ask a serious personal question – which is how patients tend to think of their concerns – and get what is in effect a canned response.

We don't like to think we dispense boilerplate, but it can be hard not to. When we see a new acne patient, how many novel and creative ways are there to present the basic spiel: no, it's not food; yes, you can use makeup; please don't pick your pimples; apply the creams and take your pills regularly; don't be discouraged if you don't clear up in 2 weeks; and, as Jerry Seinfeld might add, "Yadda yadda yadda."

The same is true for eczema, warts, or any of the routine things any dermatologist deals with daily. How tempting is it to succumb and dispense boilerplate? You've got disease X? Here is response Y. Gotta go now.

But avoiding this is indeed possible without a lot of effort or time. The first step is to recognize the problem and listen to ourselves as though we're the patient. The second is to vary the mode of presentation, even if just a bit, between one visit and the next (changing sentence order, modifying phrasing.) The third is to add emphasis to show we're making a point we really want to put across and that it does matter whether the patient understands the instructions and knows how to follow the directions. The fourth is to maintain eye contact and vary inflection to show that we are not, in fact, automated attendants giving recorded announcements with implied or explicit disclaimers, that the opinions herein expressed are not those of the management, the medical society, or the Department of Homeland Security.

Written boilerplate in a contract or lease agreement has lots of words in tiny print to show that you don't have to spend time reading it. Verbal boilerplate sends a similar message: careful listening isn't required. In that case, why bother saying it?

A week after my gurney epiphany, I got a letter from the gastroenterologist telling me I don't need another colonoscopy for 5 years. Now that's what I call meaningful communication.

I was in a most undignified position: lying on a gurney in a curtained cubicle, wearing a johnny under a flimsy sheet, awaiting my 5-year colonoscopy and feeling, well, washed out. That's when I overheard a doctor's voice from the next cubicle.

"Everything looked fine, Mrs. Jenkins," said the voice. "Just some small external hemorrhoids. You might consider drinking a lot of water and eating a fiber-rich diet."

Although I'm no gastroenterologist, I know it when I hear it: verbal boilerplate. I even know it when I say it, though I try not to.

Boilerplate language is a Victorian-age metaphor. From steel sheets that could be used over and over in different machines without change came the idea of reusable units of writing – no thought needed.

We all use verbal boilerplates every day, in and out of the office. ("How's everything?" "Fine. "What's happening?" "Not much.") Verbal boilerplate has two qualities: it's delivered without much inflection, and it doesn't convey a lot of information. Of course, the second quality can be helpful. You don't really want to know how everything is, do you?

But in a professional context, boilerplate has drawbacks. The way it's delivered signals what's really going on. That's how, chilly and distracted though I was, I sensed I was hearing verbal boilerplate even before the words registered. The delivery was quieter, faster, flatter. Hemorrhoids? Press mental button: lots-of-water-fiber-rich-diet.

The second aspect, not unrelated, is that verbal boilerplate is technically correct but doesn't say much. How much water is "lots?" How much fiber is "fiber-rich?" What kind of fiber? How often?

Maybe it doesn't really matter, but that's exactly the point: when you communicate with verbal boilerplate, what you're really saying is, "I'm telling you something I'm supposed to, but whether you understand or follow my advice isn't all that important."

Such communication presents problems. The first, from a medical standpoint, is that signaling that a piece of advice isn't crucial doesn't exactly promote adherence. (Reading compliance studies is always depressing anyway.) The second, from an ordinary human perspective, is that it's deflating to ask a serious personal question – which is how patients tend to think of their concerns – and get what is in effect a canned response.

We don't like to think we dispense boilerplate, but it can be hard not to. When we see a new acne patient, how many novel and creative ways are there to present the basic spiel: no, it's not food; yes, you can use makeup; please don't pick your pimples; apply the creams and take your pills regularly; don't be discouraged if you don't clear up in 2 weeks; and, as Jerry Seinfeld might add, "Yadda yadda yadda."

The same is true for eczema, warts, or any of the routine things any dermatologist deals with daily. How tempting is it to succumb and dispense boilerplate? You've got disease X? Here is response Y. Gotta go now.

But avoiding this is indeed possible without a lot of effort or time. The first step is to recognize the problem and listen to ourselves as though we're the patient. The second is to vary the mode of presentation, even if just a bit, between one visit and the next (changing sentence order, modifying phrasing.) The third is to add emphasis to show we're making a point we really want to put across and that it does matter whether the patient understands the instructions and knows how to follow the directions. The fourth is to maintain eye contact and vary inflection to show that we are not, in fact, automated attendants giving recorded announcements with implied or explicit disclaimers, that the opinions herein expressed are not those of the management, the medical society, or the Department of Homeland Security.

Written boilerplate in a contract or lease agreement has lots of words in tiny print to show that you don't have to spend time reading it. Verbal boilerplate sends a similar message: careful listening isn't required. In that case, why bother saying it?

A week after my gurney epiphany, I got a letter from the gastroenterologist telling me I don't need another colonoscopy for 5 years. Now that's what I call meaningful communication.

Last month a patient sent me an essay from The New York Times ("How Mindfulness Can Make for Better Doctors," Oct. 15, 2009) which cited a study showing that meditation and mindfulness can help combat physician burnout. The columnist, Dr. Pauline W. Chen, spoke of an older colleague whose love for what he does was being drained by paperwork, e-mails, and other sundry joys of modern medical life.

It's only natural to compare yourself with others close by in time, place, and situation. Nobody ever says, "Times are tough, but I'm a darn sight better off than if I'd been a peasant in 16th century Belgium or if I were born in Burundi."

Still, comparative perspective is readily available. All day patients troop into our offices who can describe how things are in their respective careers. Just ask.

There's Janice, a 50ish attorney who left the law firm where she had been a long-time partner to work in-house for a corporation. How come?

"They expected me to spend my social life schmoozing potential clients. That wasn't going to work, so I grabbed this new opportunity," she said. "It is not really what I wanted, but at my age, I figured it would be the best I could get." Janice said she never had to generate business before. "Other people made the rain, and I did the work. But now everything is so competitive."

Then there's Larry, just past 60. He does insurance work and has been trying to develop a retirement consulting business. During the recent financial meltdown he had some success selling annuities to people fleeing what they had thought were safe investments, only now his leads have dried up. "I offered to give talks for free at the local library, but they weren't interested." he said. "Too many other people have already talked about the same thing. Do you know anyone I can approach?"

Marian's been a teacher for more than 30 years. Asked how things have changed, she shakes her head. "We used to use creativity," she said. "Now there are rigid standards and statewide exams the kids have to take, and we have to teach to the test. No leeway at all. I love the children, but frankly, it's not fun anymore. I don't know how much more of this I can take." (Clinical algorithms anyone?)

Stan, himself, is almost retired. "We own a string of doughnut franchises," he said. "But I have younger partners who mostly run it."

Sounds sweet: people line up for doughnuts and coffee, and the owners carry bags of cash to the bank. "How is the economy affecting you?" I asked.

"We're off a little," he said. "And there's theft to contend with."

"What do people steal, doughnuts?"

"Cash," said Stan. "I have had high-tech surveillance equipment, so I can keep tabs on the staff and watch the registers from my living room. Now I leave that to my partners--it takes a lot of hours to watch those tapes. When I started out, I used to sleep in the store. It wasn't just theft, but lots of times the staff just doesn't show up, including the baker. And like the ad says, somebody has to get up to make the doughnuts."

Small business people can do very well, but there's a reason why so many of their children become professionals. As for professionals themselves, conversations with those in law, accounting, and education suggest broad social trends affecting every profession across the board: increased bureaucratization, more government regulation and oversight, less flexibility, more paperwork, tougher competition, more financial pressure, and less of the easygoing collegiality people like to think they remember. And of course there are more faxes, voice mails, e-mails, and other Internet-aged intrusions that blur the line between work and leisure, and reduce the expectation of privacy to near zero.

I haven't even mentioned, of course, those who are out of work altogether, with few or no prospects.

For us physicians, then, it's perhaps worth a moment of mindful reflection on the comfort of working in a respectable and respected profession that will probably never compel us to troll for trade into our seventh decade, or throw us overboard in midlife because we're too expensive or our wisdom is undervalued and deemed expendable, or our services have been re-engineered or outsourced, or because our whole industry has been eaten by Google.

As the old Latin proverb has it: Times change, and we change with them.

We don't have to change, of course. We can always leave or meditate, I guess.

Last month a patient sent me an essay from The New York Times ("How Mindfulness Can Make for Better Doctors," Oct. 15, 2009) which cited a study showing that meditation and mindfulness can help combat physician burnout. The columnist, Dr. Pauline W. Chen, spoke of an older colleague whose love for what he does was being drained by paperwork, e-mails, and other sundry joys of modern medical life.

It's only natural to compare yourself with others close by in time, place, and situation. Nobody ever says, "Times are tough, but I'm a darn sight better off than if I'd been a peasant in 16th century Belgium or if I were born in Burundi."

Still, comparative perspective is readily available. All day patients troop into our offices who can describe how things are in their respective careers. Just ask.

There's Janice, a 50ish attorney who left the law firm where she had been a long-time partner to work in-house for a corporation. How come?

"They expected me to spend my social life schmoozing potential clients. That wasn't going to work, so I grabbed this new opportunity," she said. "It is not really what I wanted, but at my age, I figured it would be the best I could get." Janice said she never had to generate business before. "Other people made the rain, and I did the work. But now everything is so competitive."

Then there's Larry, just past 60. He does insurance work and has been trying to develop a retirement consulting business. During the recent financial meltdown he had some success selling annuities to people fleeing what they had thought were safe investments, only now his leads have dried up. "I offered to give talks for free at the local library, but they weren't interested." he said. "Too many other people have already talked about the same thing. Do you know anyone I can approach?"

Marian's been a teacher for more than 30 years. Asked how things have changed, she shakes her head. "We used to use creativity," she said. "Now there are rigid standards and statewide exams the kids have to take, and we have to teach to the test. No leeway at all. I love the children, but frankly, it's not fun anymore. I don't know how much more of this I can take." (Clinical algorithms anyone?)

Stan, himself, is almost retired. "We own a string of doughnut franchises," he said. "But I have younger partners who mostly run it."

Sounds sweet: people line up for doughnuts and coffee, and the owners carry bags of cash to the bank. "How is the economy affecting you?" I asked.

"We're off a little," he said. "And there's theft to contend with."

"What do people steal, doughnuts?"

"Cash," said Stan. "I have had high-tech surveillance equipment, so I can keep tabs on the staff and watch the registers from my living room. Now I leave that to my partners--it takes a lot of hours to watch those tapes. When I started out, I used to sleep in the store. It wasn't just theft, but lots of times the staff just doesn't show up, including the baker. And like the ad says, somebody has to get up to make the doughnuts."

Small business people can do very well, but there's a reason why so many of their children become professionals. As for professionals themselves, conversations with those in law, accounting, and education suggest broad social trends affecting every profession across the board: increased bureaucratization, more government regulation and oversight, less flexibility, more paperwork, tougher competition, more financial pressure, and less of the easygoing collegiality people like to think they remember. And of course there are more faxes, voice mails, e-mails, and other Internet-aged intrusions that blur the line between work and leisure, and reduce the expectation of privacy to near zero.

I haven't even mentioned, of course, those who are out of work altogether, with few or no prospects.

For us physicians, then, it's perhaps worth a moment of mindful reflection on the comfort of working in a respectable and respected profession that will probably never compel us to troll for trade into our seventh decade, or throw us overboard in midlife because we're too expensive or our wisdom is undervalued and deemed expendable, or our services have been re-engineered or outsourced, or because our whole industry has been eaten by Google.

As the old Latin proverb has it: Times change, and we change with them.

We don't have to change, of course. We can always leave or meditate, I guess.

Last month a patient sent me an essay from The New York Times ("How Mindfulness Can Make for Better Doctors," Oct. 15, 2009) which cited a study showing that meditation and mindfulness can help combat physician burnout. The columnist, Dr. Pauline W. Chen, spoke of an older colleague whose love for what he does was being drained by paperwork, e-mails, and other sundry joys of modern medical life.

It's only natural to compare yourself with others close by in time, place, and situation. Nobody ever says, "Times are tough, but I'm a darn sight better off than if I'd been a peasant in 16th century Belgium or if I were born in Burundi."

Still, comparative perspective is readily available. All day patients troop into our offices who can describe how things are in their respective careers. Just ask.

There's Janice, a 50ish attorney who left the law firm where she had been a long-time partner to work in-house for a corporation. How come?

"They expected me to spend my social life schmoozing potential clients. That wasn't going to work, so I grabbed this new opportunity," she said. "It is not really what I wanted, but at my age, I figured it would be the best I could get." Janice said she never had to generate business before. "Other people made the rain, and I did the work. But now everything is so competitive."

Then there's Larry, just past 60. He does insurance work and has been trying to develop a retirement consulting business. During the recent financial meltdown he had some success selling annuities to people fleeing what they had thought were safe investments, only now his leads have dried up. "I offered to give talks for free at the local library, but they weren't interested." he said. "Too many other people have already talked about the same thing. Do you know anyone I can approach?"

Marian's been a teacher for more than 30 years. Asked how things have changed, she shakes her head. "We used to use creativity," she said. "Now there are rigid standards and statewide exams the kids have to take, and we have to teach to the test. No leeway at all. I love the children, but frankly, it's not fun anymore. I don't know how much more of this I can take." (Clinical algorithms anyone?)

Stan, himself, is almost retired. "We own a string of doughnut franchises," he said. "But I have younger partners who mostly run it."

Sounds sweet: people line up for doughnuts and coffee, and the owners carry bags of cash to the bank. "How is the economy affecting you?" I asked.

"We're off a little," he said. "And there's theft to contend with."

"What do people steal, doughnuts?"

"Cash," said Stan. "I have had high-tech surveillance equipment, so I can keep tabs on the staff and watch the registers from my living room. Now I leave that to my partners--it takes a lot of hours to watch those tapes. When I started out, I used to sleep in the store. It wasn't just theft, but lots of times the staff just doesn't show up, including the baker. And like the ad says, somebody has to get up to make the doughnuts."

Small business people can do very well, but there's a reason why so many of their children become professionals. As for professionals themselves, conversations with those in law, accounting, and education suggest broad social trends affecting every profession across the board: increased bureaucratization, more government regulation and oversight, less flexibility, more paperwork, tougher competition, more financial pressure, and less of the easygoing collegiality people like to think they remember. And of course there are more faxes, voice mails, e-mails, and other Internet-aged intrusions that blur the line between work and leisure, and reduce the expectation of privacy to near zero.

I haven't even mentioned, of course, those who are out of work altogether, with few or no prospects.

For us physicians, then, it's perhaps worth a moment of mindful reflection on the comfort of working in a respectable and respected profession that will probably never compel us to troll for trade into our seventh decade, or throw us overboard in midlife because we're too expensive or our wisdom is undervalued and deemed expendable, or our services have been re-engineered or outsourced, or because our whole industry has been eaten by Google.

As the old Latin proverb has it: Times change, and we change with them.

We don't have to change, of course. We can always leave or meditate, I guess.

Probably like many who work with the public, I often get the chance to see how little sense people can make. Even so, last week was unusual.

On Tuesday, I saw Beulah who had not been into my office for 8 years. “I showed Dr. Prince this spot on my leg,” she said. “It's been there a month, and I'm worried about it.”

“Just a blocked follicle,” I told her. “Put some bacitracin on it, and it will be fine.”

Beulah sighed with relief. “I don't need another cancer,” she said. “I already have stomach cancer. Dr. Prince told me I couldn't have surgery or any other treatment, because I wouldn't make it through. But I'm 98 years old, and I guess we all have to go sometime. I don't have any family left. They're all gone.

“I've lost 30 pounds,” she said, still spry enough to hop off the exam table. “None of my clothes fit anymore. But it's awfully good to hear that I don't have to worry about that spot on my leg.”

That is a relief, I agreed.

The next morning, I greeted Iris warmly. “How are those grandchildren?” she asked, as she always does. “Do you have any new pictures?”

“I thought you were moving to Florida, Iris,” I said.

“It's been a tough year,” she said, “so I had to come back.” She went on to tell me how her husband had become jaundiced and succumbed in less than 3 months to cancer of the bile duct. “It's crazy, Doctor,” she said. “Both of his brothers had cancer, they had operations years ago, and they're fine. My husband was never sick a day in his life, never even had to take anything for a headache. And now he's gone.”

We talked about Iris's own problem, scleroderma, which somehow was not progressing at all. Her only skin complaint, easily disposed of, was mild hand eczema.

After some further pleasantries and picture showing, Iris took out a bag of skin care products. “I'm running low on these,” she said. “Is there any way I could get some while I'm here?”

Sure she could.

Then on Thursday, Sybil came by, a robust woman of 79 who wanted some pigmented lesions checked. As I looked her over, I asked about her family.

“My baby brother has Lewy bodies dementia,” she said. “He's not doing very well. He's in a nursing home now, because his family couldn't take care of him anymore. He still recognizes us a little, or seems to, when we come to visit. It's very painful to watch.”

Then Sybil brightened, pointing to the brown spots on the backs of her hands. Can we laser these off?” she asked. “I really hate them.”

Of course we can.

By week's end, I was really perplexed. How do people do that, I wondered? How can they go from the profound to the trivial with no acknowledgment, no apology, no, “I know this will sound frivolous after what I just told you?” How do they manage such a sudden and seamless register change—as though an opera singer stopped mid aria and launched into “Jingle Bells” without so much as a wink? But they do. I am just about gone; I have outlived everyone around, but what a relief that I don't have skin cancer. My husband just died a painful and senseless death, but I need those creams to help my skin look younger. My little brother is wasting away before my eyes, and how about those pesky age spots.

On reflection, such paradoxes may be more apparent than real. Unless we succumb to deep depression or utter despair, we want to go on living. This means setting aside gloomy thoughts, even if just for a while, and attending to all matters, profound or trivial, that people pay attention to until giving up altogether.

Since no one can make tragedy go away, I guess it's nice to be able to mitigate its impact just a little now and then.

But the end of last week left me shaking my head. I hope never to stop trying, but I doubt that I'll ever really understand people as long as I live.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, email Dr. Rockoff at our editorial offices at [email protected]

Probably like many who work with the public, I often get the chance to see how little sense people can make. Even so, last week was unusual.

On Tuesday, I saw Beulah who had not been into my office for 8 years. “I showed Dr. Prince this spot on my leg,” she said. “It's been there a month, and I'm worried about it.”

“Just a blocked follicle,” I told her. “Put some bacitracin on it, and it will be fine.”

Beulah sighed with relief. “I don't need another cancer,” she said. “I already have stomach cancer. Dr. Prince told me I couldn't have surgery or any other treatment, because I wouldn't make it through. But I'm 98 years old, and I guess we all have to go sometime. I don't have any family left. They're all gone.

“I've lost 30 pounds,” she said, still spry enough to hop off the exam table. “None of my clothes fit anymore. But it's awfully good to hear that I don't have to worry about that spot on my leg.”

That is a relief, I agreed.

The next morning, I greeted Iris warmly. “How are those grandchildren?” she asked, as she always does. “Do you have any new pictures?”

“I thought you were moving to Florida, Iris,” I said.

“It's been a tough year,” she said, “so I had to come back.” She went on to tell me how her husband had become jaundiced and succumbed in less than 3 months to cancer of the bile duct. “It's crazy, Doctor,” she said. “Both of his brothers had cancer, they had operations years ago, and they're fine. My husband was never sick a day in his life, never even had to take anything for a headache. And now he's gone.”

We talked about Iris's own problem, scleroderma, which somehow was not progressing at all. Her only skin complaint, easily disposed of, was mild hand eczema.

After some further pleasantries and picture showing, Iris took out a bag of skin care products. “I'm running low on these,” she said. “Is there any way I could get some while I'm here?”

Sure she could.

Then on Thursday, Sybil came by, a robust woman of 79 who wanted some pigmented lesions checked. As I looked her over, I asked about her family.

“My baby brother has Lewy bodies dementia,” she said. “He's not doing very well. He's in a nursing home now, because his family couldn't take care of him anymore. He still recognizes us a little, or seems to, when we come to visit. It's very painful to watch.”

Then Sybil brightened, pointing to the brown spots on the backs of her hands. Can we laser these off?” she asked. “I really hate them.”

Of course we can.

By week's end, I was really perplexed. How do people do that, I wondered? How can they go from the profound to the trivial with no acknowledgment, no apology, no, “I know this will sound frivolous after what I just told you?” How do they manage such a sudden and seamless register change—as though an opera singer stopped mid aria and launched into “Jingle Bells” without so much as a wink? But they do. I am just about gone; I have outlived everyone around, but what a relief that I don't have skin cancer. My husband just died a painful and senseless death, but I need those creams to help my skin look younger. My little brother is wasting away before my eyes, and how about those pesky age spots.

On reflection, such paradoxes may be more apparent than real. Unless we succumb to deep depression or utter despair, we want to go on living. This means setting aside gloomy thoughts, even if just for a while, and attending to all matters, profound or trivial, that people pay attention to until giving up altogether.

Since no one can make tragedy go away, I guess it's nice to be able to mitigate its impact just a little now and then.

But the end of last week left me shaking my head. I hope never to stop trying, but I doubt that I'll ever really understand people as long as I live.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, email Dr. Rockoff at our editorial offices at [email protected]

Probably like many who work with the public, I often get the chance to see how little sense people can make. Even so, last week was unusual.

On Tuesday, I saw Beulah who had not been into my office for 8 years. “I showed Dr. Prince this spot on my leg,” she said. “It's been there a month, and I'm worried about it.”

“Just a blocked follicle,” I told her. “Put some bacitracin on it, and it will be fine.”

Beulah sighed with relief. “I don't need another cancer,” she said. “I already have stomach cancer. Dr. Prince told me I couldn't have surgery or any other treatment, because I wouldn't make it through. But I'm 98 years old, and I guess we all have to go sometime. I don't have any family left. They're all gone.

“I've lost 30 pounds,” she said, still spry enough to hop off the exam table. “None of my clothes fit anymore. But it's awfully good to hear that I don't have to worry about that spot on my leg.”

That is a relief, I agreed.

The next morning, I greeted Iris warmly. “How are those grandchildren?” she asked, as she always does. “Do you have any new pictures?”

“I thought you were moving to Florida, Iris,” I said.

“It's been a tough year,” she said, “so I had to come back.” She went on to tell me how her husband had become jaundiced and succumbed in less than 3 months to cancer of the bile duct. “It's crazy, Doctor,” she said. “Both of his brothers had cancer, they had operations years ago, and they're fine. My husband was never sick a day in his life, never even had to take anything for a headache. And now he's gone.”

We talked about Iris's own problem, scleroderma, which somehow was not progressing at all. Her only skin complaint, easily disposed of, was mild hand eczema.

After some further pleasantries and picture showing, Iris took out a bag of skin care products. “I'm running low on these,” she said. “Is there any way I could get some while I'm here?”

Sure she could.

Then on Thursday, Sybil came by, a robust woman of 79 who wanted some pigmented lesions checked. As I looked her over, I asked about her family.

“My baby brother has Lewy bodies dementia,” she said. “He's not doing very well. He's in a nursing home now, because his family couldn't take care of him anymore. He still recognizes us a little, or seems to, when we come to visit. It's very painful to watch.”

Then Sybil brightened, pointing to the brown spots on the backs of her hands. Can we laser these off?” she asked. “I really hate them.”

Of course we can.

By week's end, I was really perplexed. How do people do that, I wondered? How can they go from the profound to the trivial with no acknowledgment, no apology, no, “I know this will sound frivolous after what I just told you?” How do they manage such a sudden and seamless register change—as though an opera singer stopped mid aria and launched into “Jingle Bells” without so much as a wink? But they do. I am just about gone; I have outlived everyone around, but what a relief that I don't have skin cancer. My husband just died a painful and senseless death, but I need those creams to help my skin look younger. My little brother is wasting away before my eyes, and how about those pesky age spots.

On reflection, such paradoxes may be more apparent than real. Unless we succumb to deep depression or utter despair, we want to go on living. This means setting aside gloomy thoughts, even if just for a while, and attending to all matters, profound or trivial, that people pay attention to until giving up altogether.

Since no one can make tragedy go away, I guess it's nice to be able to mitigate its impact just a little now and then.

But the end of last week left me shaking my head. I hope never to stop trying, but I doubt that I'll ever really understand people as long as I live.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, email Dr. Rockoff at our editorial offices at [email protected]