Under My Skin

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

As a senior medical student, I spent an outpatient January in the office of a suburban pediatrician who cared for the children of many doctors.

After the holidays, he mused about the onslaught of gifts that he received from people to whom he extended professional courtesy.

Some gave him conventional things—candy, wine, and so forth. Others aimed for something more grandiose. Like the one who the year before had sent him a side of beef.

This is the season when many people get to ponder the intricacies of giving and getting gifts. Knowing when and what to give, as well as how to accept, requires a lot of art and sensitivity. (“That's exactly what I wanted! How did you know?”)

Thankfully, such subtleties are less important for doctors, at least at work, now that health insurance and fixed copayments have made most professional courtesy obsolete. I doubt many miss it. Professional relationships work best when objectivity is not undercut by other considerations. Like handouts.

Gifts haven't gone away, though, even if we're going to have to do without pens, mugs, and sticky notes from pharmaceutical companies. Some of my patients still like to bring presents. One Russian patient handed me a box of chocolates covered in Cyrillic script and funky Russian, ruby-red graphics. I protested that she really shouldn't have (though of course not too strongly, so as not to offend). Bringing the gift clearly makes her happy, and my staff eats the chocolate.

Many of my Russian patients like to bring gifts. Besides chocolate, they present wine and other spirits. One Russian physician brought a bottle of Armenian vodka in a bottle whose odd shape I couldn't make any sense of until he showed me how to hold it: It was shaped like a boxing glove! I show it to house guests, but it's just too weird for me to open. (Some time later I saw another vodka bottle from the former Soviet Union, this one shaped like a submachine gun.)

Other ethnic groups bring presents too. A Chinese patient generally brings cookies from Chinatown, and sometimes tea. Pamela brings a loaf of Irish bread every time she comes for Botox. She says she knows how much I like it.

I have no idea how she could know this, since I have never eaten an Irish bread, but I don't have the heart to tell her. My head nurse, Faye, grew up in South Boston. (If you can't locate Southie on the physical and cultural map, check out Matt Damon in “Good Will Hunting.”) Faye likes Irish bread, including Pamela's.

So far the examples I've given reflect varieties of ethnic expression and traditional patterns of gift-giving left over from old countries. Other presents are personal expressions—authors bring in a copy of their latest book, musicians drop off a CD. One patient last year brought an art calendar her mother had illustrated. A very elderly gentleman came by a few years ago, and reminded me that I had seen him decades before when I first went into practice. In his 90s, he was still busy making mobiles, and he brought me one. I couldn't bear to throw it out but had no idea what to do with it, so I hung it behind a door for a long time. Eventually, like most such things, it went.

Then some gifts, like their givers, are just, well, odd. One gentleman came a few years ago for a minor problem that cleared by the second visit. Before he left, he rather solemnly announced that he was so grateful for my intervention that he had purchased a gift. He reached into a tin bucket he'd brought and withdrew a short, green brush, the kind you use to wash dishes, and presented it to me. The price tag was still attached—49 cents.

I was speechless. I still am. The gift brush sits on my window sill, reminding me of the importance of going the extra mile for patients, of washing dishes, and of buying things on sale.

Hope you had happy holidays (and got the gifts you wanted)!

As a senior medical student, I spent an outpatient January in the office of a suburban pediatrician who cared for the children of many doctors.

After the holidays, he mused about the onslaught of gifts that he received from people to whom he extended professional courtesy.

Some gave him conventional things—candy, wine, and so forth. Others aimed for something more grandiose. Like the one who the year before had sent him a side of beef.

This is the season when many people get to ponder the intricacies of giving and getting gifts. Knowing when and what to give, as well as how to accept, requires a lot of art and sensitivity. (“That's exactly what I wanted! How did you know?”)

Thankfully, such subtleties are less important for doctors, at least at work, now that health insurance and fixed copayments have made most professional courtesy obsolete. I doubt many miss it. Professional relationships work best when objectivity is not undercut by other considerations. Like handouts.

Gifts haven't gone away, though, even if we're going to have to do without pens, mugs, and sticky notes from pharmaceutical companies. Some of my patients still like to bring presents. One Russian patient handed me a box of chocolates covered in Cyrillic script and funky Russian, ruby-red graphics. I protested that she really shouldn't have (though of course not too strongly, so as not to offend). Bringing the gift clearly makes her happy, and my staff eats the chocolate.

Many of my Russian patients like to bring gifts. Besides chocolate, they present wine and other spirits. One Russian physician brought a bottle of Armenian vodka in a bottle whose odd shape I couldn't make any sense of until he showed me how to hold it: It was shaped like a boxing glove! I show it to house guests, but it's just too weird for me to open. (Some time later I saw another vodka bottle from the former Soviet Union, this one shaped like a submachine gun.)

Other ethnic groups bring presents too. A Chinese patient generally brings cookies from Chinatown, and sometimes tea. Pamela brings a loaf of Irish bread every time she comes for Botox. She says she knows how much I like it.

I have no idea how she could know this, since I have never eaten an Irish bread, but I don't have the heart to tell her. My head nurse, Faye, grew up in South Boston. (If you can't locate Southie on the physical and cultural map, check out Matt Damon in “Good Will Hunting.”) Faye likes Irish bread, including Pamela's.

So far the examples I've given reflect varieties of ethnic expression and traditional patterns of gift-giving left over from old countries. Other presents are personal expressions—authors bring in a copy of their latest book, musicians drop off a CD. One patient last year brought an art calendar her mother had illustrated. A very elderly gentleman came by a few years ago, and reminded me that I had seen him decades before when I first went into practice. In his 90s, he was still busy making mobiles, and he brought me one. I couldn't bear to throw it out but had no idea what to do with it, so I hung it behind a door for a long time. Eventually, like most such things, it went.

Then some gifts, like their givers, are just, well, odd. One gentleman came a few years ago for a minor problem that cleared by the second visit. Before he left, he rather solemnly announced that he was so grateful for my intervention that he had purchased a gift. He reached into a tin bucket he'd brought and withdrew a short, green brush, the kind you use to wash dishes, and presented it to me. The price tag was still attached—49 cents.

I was speechless. I still am. The gift brush sits on my window sill, reminding me of the importance of going the extra mile for patients, of washing dishes, and of buying things on sale.

Hope you had happy holidays (and got the gifts you wanted)!

As a senior medical student, I spent an outpatient January in the office of a suburban pediatrician who cared for the children of many doctors.

After the holidays, he mused about the onslaught of gifts that he received from people to whom he extended professional courtesy.

Some gave him conventional things—candy, wine, and so forth. Others aimed for something more grandiose. Like the one who the year before had sent him a side of beef.

This is the season when many people get to ponder the intricacies of giving and getting gifts. Knowing when and what to give, as well as how to accept, requires a lot of art and sensitivity. (“That's exactly what I wanted! How did you know?”)

Thankfully, such subtleties are less important for doctors, at least at work, now that health insurance and fixed copayments have made most professional courtesy obsolete. I doubt many miss it. Professional relationships work best when objectivity is not undercut by other considerations. Like handouts.

Gifts haven't gone away, though, even if we're going to have to do without pens, mugs, and sticky notes from pharmaceutical companies. Some of my patients still like to bring presents. One Russian patient handed me a box of chocolates covered in Cyrillic script and funky Russian, ruby-red graphics. I protested that she really shouldn't have (though of course not too strongly, so as not to offend). Bringing the gift clearly makes her happy, and my staff eats the chocolate.

Many of my Russian patients like to bring gifts. Besides chocolate, they present wine and other spirits. One Russian physician brought a bottle of Armenian vodka in a bottle whose odd shape I couldn't make any sense of until he showed me how to hold it: It was shaped like a boxing glove! I show it to house guests, but it's just too weird for me to open. (Some time later I saw another vodka bottle from the former Soviet Union, this one shaped like a submachine gun.)

Other ethnic groups bring presents too. A Chinese patient generally brings cookies from Chinatown, and sometimes tea. Pamela brings a loaf of Irish bread every time she comes for Botox. She says she knows how much I like it.

I have no idea how she could know this, since I have never eaten an Irish bread, but I don't have the heart to tell her. My head nurse, Faye, grew up in South Boston. (If you can't locate Southie on the physical and cultural map, check out Matt Damon in “Good Will Hunting.”) Faye likes Irish bread, including Pamela's.

So far the examples I've given reflect varieties of ethnic expression and traditional patterns of gift-giving left over from old countries. Other presents are personal expressions—authors bring in a copy of their latest book, musicians drop off a CD. One patient last year brought an art calendar her mother had illustrated. A very elderly gentleman came by a few years ago, and reminded me that I had seen him decades before when I first went into practice. In his 90s, he was still busy making mobiles, and he brought me one. I couldn't bear to throw it out but had no idea what to do with it, so I hung it behind a door for a long time. Eventually, like most such things, it went.

Then some gifts, like their givers, are just, well, odd. One gentleman came a few years ago for a minor problem that cleared by the second visit. Before he left, he rather solemnly announced that he was so grateful for my intervention that he had purchased a gift. He reached into a tin bucket he'd brought and withdrew a short, green brush, the kind you use to wash dishes, and presented it to me. The price tag was still attached—49 cents.

I was speechless. I still am. The gift brush sits on my window sill, reminding me of the importance of going the extra mile for patients, of washing dishes, and of buying things on sale.

Hope you had happy holidays (and got the gifts you wanted)!

“Why, oh why, oh why, oh,” my mother used to sing when I was a kid, “Why did I ever leave Ohio?” That's one of those sentimental home-state songs, like “The Missouri Waltz,” “Stars Fell on Alabama,” “I Love New York,” and “See the USA in Your Chevrolet.”

I never had the chance to leave Ohio until last month, when I found myself in Columbus, addressing the Ohio Dermatological Association on its 25th anniversary. Since I started practice almost 30 years ago, that makes me, in a sense, dermatologically older than Ohio. In my talk, “37 Steps to a Successful Practice,” I tried to impart the deep wisdom of experience about how to get ahead in our changing practice environment.

Because 37 is a lot of steps, I limited my remarks to the most crucial: branding, marketing, self-promotion, intensive use of the Internet through creative placement of Web site keywords and Facebook networking, and of course, office decoration according to the principles of Feng Shui.

For some reason, my Ohio colleagues found these thoughtful suggestions laughable. They gave the same response to my innovative plan to make sure patients come back for regular skin checks: an inspection sticker, color-coded by month and affixed to the neck below the angle of the jaw with superglue. This would allow people to peer over the collar of friends and family and say, “Oh, look—you've expired!” Well, I thought it was a good idea. It might even help with pay for performance.

I'm just glad I'm not running for office. Who can predict the responses of these denizens of America's heartland?

Afterward, I had a chance to speak with some of my Ohio colleagues, who seemed to be a refreshingly down-to-earth group. One Mohs surgeon told me that he likes to quiz his fellows by asking them what they consider the most important part of an interview with a prospective patient. After they disgorge what they think he wants to hear (details of the procedure and so on), he shakes his head and says, “Nope. It's showing them you're a good guy who knows what he's doing.”

“I guess we all learn that when we get out in the world,” I said.

“A lot of us don't,” he replied.

The others I met were in practice in Columbus and around the state, mostly in large groups. Several told me that they practice general dermatology. Some seemed almost apologetic when they added that they don't do much cosmetic work, as though that meant they were somehow behind the curve. If so, apologies were unnecessary.

One can certainly get the impression from all the advertising and hype that dermatology is morphing into a species of cosmetic surgery or advanced aesthetics. I provide laser and cosmetic services, carried along like others by the tides of fashion and patient expectations, but I'm still not comfortable with this trend.

Among other things, laser and cosmetic work has brought the modes of marketing into our medical world: coupons, promotions, branding—that sort of thing.

Of course, marketing has made large inroads in traditional medical areas too. Within 10 minutes, the rock station I heard at the gym last week blared two promotions for prominent teaching hospitals providing orthopedic and psychiatric services.

Our sample closets fill with discount coupons to mitigate tiered copays, along with “bundled” products (buy this prescription topical, get this over-the-counter cleanser free!). Nothing wrong with any of this, perhaps, but it just highlights how blurry distinctions have become between medicine and retail.

I'm sure plenty of doctors in Ohio and throughout Middle America perform cosmetic procedures with skill and gusto. Just yesterday a Google ad popped up on my e-mail for a laser center in Indianapolis. (I booked a flight at once.)

It was nice, however, to meet a few colleagues whose practices are still mostly or entirely “just general derm.”

Getting patients to look younger and feel good about themselves is a worthy goal. Someone ought to be doing this. But helping sick people get better is, I think, the reason we went to medical school.

“Why, oh why, oh why, oh,” my mother used to sing when I was a kid, “Why did I ever leave Ohio?” That's one of those sentimental home-state songs, like “The Missouri Waltz,” “Stars Fell on Alabama,” “I Love New York,” and “See the USA in Your Chevrolet.”

I never had the chance to leave Ohio until last month, when I found myself in Columbus, addressing the Ohio Dermatological Association on its 25th anniversary. Since I started practice almost 30 years ago, that makes me, in a sense, dermatologically older than Ohio. In my talk, “37 Steps to a Successful Practice,” I tried to impart the deep wisdom of experience about how to get ahead in our changing practice environment.

Because 37 is a lot of steps, I limited my remarks to the most crucial: branding, marketing, self-promotion, intensive use of the Internet through creative placement of Web site keywords and Facebook networking, and of course, office decoration according to the principles of Feng Shui.

For some reason, my Ohio colleagues found these thoughtful suggestions laughable. They gave the same response to my innovative plan to make sure patients come back for regular skin checks: an inspection sticker, color-coded by month and affixed to the neck below the angle of the jaw with superglue. This would allow people to peer over the collar of friends and family and say, “Oh, look—you've expired!” Well, I thought it was a good idea. It might even help with pay for performance.

I'm just glad I'm not running for office. Who can predict the responses of these denizens of America's heartland?

Afterward, I had a chance to speak with some of my Ohio colleagues, who seemed to be a refreshingly down-to-earth group. One Mohs surgeon told me that he likes to quiz his fellows by asking them what they consider the most important part of an interview with a prospective patient. After they disgorge what they think he wants to hear (details of the procedure and so on), he shakes his head and says, “Nope. It's showing them you're a good guy who knows what he's doing.”

“I guess we all learn that when we get out in the world,” I said.

“A lot of us don't,” he replied.

The others I met were in practice in Columbus and around the state, mostly in large groups. Several told me that they practice general dermatology. Some seemed almost apologetic when they added that they don't do much cosmetic work, as though that meant they were somehow behind the curve. If so, apologies were unnecessary.

One can certainly get the impression from all the advertising and hype that dermatology is morphing into a species of cosmetic surgery or advanced aesthetics. I provide laser and cosmetic services, carried along like others by the tides of fashion and patient expectations, but I'm still not comfortable with this trend.

Among other things, laser and cosmetic work has brought the modes of marketing into our medical world: coupons, promotions, branding—that sort of thing.

Of course, marketing has made large inroads in traditional medical areas too. Within 10 minutes, the rock station I heard at the gym last week blared two promotions for prominent teaching hospitals providing orthopedic and psychiatric services.

Our sample closets fill with discount coupons to mitigate tiered copays, along with “bundled” products (buy this prescription topical, get this over-the-counter cleanser free!). Nothing wrong with any of this, perhaps, but it just highlights how blurry distinctions have become between medicine and retail.

I'm sure plenty of doctors in Ohio and throughout Middle America perform cosmetic procedures with skill and gusto. Just yesterday a Google ad popped up on my e-mail for a laser center in Indianapolis. (I booked a flight at once.)

It was nice, however, to meet a few colleagues whose practices are still mostly or entirely “just general derm.”

Getting patients to look younger and feel good about themselves is a worthy goal. Someone ought to be doing this. But helping sick people get better is, I think, the reason we went to medical school.

“Why, oh why, oh why, oh,” my mother used to sing when I was a kid, “Why did I ever leave Ohio?” That's one of those sentimental home-state songs, like “The Missouri Waltz,” “Stars Fell on Alabama,” “I Love New York,” and “See the USA in Your Chevrolet.”

I never had the chance to leave Ohio until last month, when I found myself in Columbus, addressing the Ohio Dermatological Association on its 25th anniversary. Since I started practice almost 30 years ago, that makes me, in a sense, dermatologically older than Ohio. In my talk, “37 Steps to a Successful Practice,” I tried to impart the deep wisdom of experience about how to get ahead in our changing practice environment.

Because 37 is a lot of steps, I limited my remarks to the most crucial: branding, marketing, self-promotion, intensive use of the Internet through creative placement of Web site keywords and Facebook networking, and of course, office decoration according to the principles of Feng Shui.

For some reason, my Ohio colleagues found these thoughtful suggestions laughable. They gave the same response to my innovative plan to make sure patients come back for regular skin checks: an inspection sticker, color-coded by month and affixed to the neck below the angle of the jaw with superglue. This would allow people to peer over the collar of friends and family and say, “Oh, look—you've expired!” Well, I thought it was a good idea. It might even help with pay for performance.

I'm just glad I'm not running for office. Who can predict the responses of these denizens of America's heartland?

Afterward, I had a chance to speak with some of my Ohio colleagues, who seemed to be a refreshingly down-to-earth group. One Mohs surgeon told me that he likes to quiz his fellows by asking them what they consider the most important part of an interview with a prospective patient. After they disgorge what they think he wants to hear (details of the procedure and so on), he shakes his head and says, “Nope. It's showing them you're a good guy who knows what he's doing.”

“I guess we all learn that when we get out in the world,” I said.

“A lot of us don't,” he replied.

The others I met were in practice in Columbus and around the state, mostly in large groups. Several told me that they practice general dermatology. Some seemed almost apologetic when they added that they don't do much cosmetic work, as though that meant they were somehow behind the curve. If so, apologies were unnecessary.

One can certainly get the impression from all the advertising and hype that dermatology is morphing into a species of cosmetic surgery or advanced aesthetics. I provide laser and cosmetic services, carried along like others by the tides of fashion and patient expectations, but I'm still not comfortable with this trend.

Among other things, laser and cosmetic work has brought the modes of marketing into our medical world: coupons, promotions, branding—that sort of thing.

Of course, marketing has made large inroads in traditional medical areas too. Within 10 minutes, the rock station I heard at the gym last week blared two promotions for prominent teaching hospitals providing orthopedic and psychiatric services.

Our sample closets fill with discount coupons to mitigate tiered copays, along with “bundled” products (buy this prescription topical, get this over-the-counter cleanser free!). Nothing wrong with any of this, perhaps, but it just highlights how blurry distinctions have become between medicine and retail.

I'm sure plenty of doctors in Ohio and throughout Middle America perform cosmetic procedures with skill and gusto. Just yesterday a Google ad popped up on my e-mail for a laser center in Indianapolis. (I booked a flight at once.)

It was nice, however, to meet a few colleagues whose practices are still mostly or entirely “just general derm.”

Getting patients to look younger and feel good about themselves is a worthy goal. Someone ought to be doing this. But helping sick people get better is, I think, the reason we went to medical school.

Joan showed me the muddy pigmentation on the side of her neck.

“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.

“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”

Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.

Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.

“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.

I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.

Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”

I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.

Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?

Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.

My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.

Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)

Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.

Joan showed me the muddy pigmentation on the side of her neck.

“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.

“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”

Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.

Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.

“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.

I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.

Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”

I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.

Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?

Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.

My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.

Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)

Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.

Joan showed me the muddy pigmentation on the side of her neck.

“That has a fancy name,” I explained. “It's called poikiloderma, but it's basically chronic sun damage.” I was about to launch into one of my riveting discourses on Greek etymology and the life and times of Jean Civatte, but Joan interrupted.

“I got this from my perfume,” she said. “It made me irritated and changed my skin. First it was just on one side, but now it's on both.”

Of course, this made no sense and ran counter to what I had just said, but I've learned not to contradict patients when they explain how things happened to them. I make exceptions only when countering their theory promises to make a real difference, and even then it's an uphill battle.

Connie got MRSA 2 years ago and was worried she had it again. In fact, all she had was a cyst on her back, but she knew for sure how she'd gotten MRSA the first time.

“My husband used clothes from the gym,” she explained, certain my student and I would be appalled, which of course we made a polite show of being. “Never mind towels,” she went on. “They even cleaned jockstraps and let clients use them. Can you imagine?” We couldn't.

I expressed surprise that in an athletic culture certain that sweat conveys all kinds of health evils, they would lend out used clothing. “I sure don't let my husband do that anymore,” she said. We sighed with relief.

Then there was Ron, who presented with rosacea all over his face. He too knew just how he got it. “I put tretinoin on my temple and it irritated it,” he said. “Now I have this rash.”

I could, of course, have pointed out how these explanations are inaccurate and don't even work on their own terms. I might have told Joan that her skin changes preceded her use of the offending perfume, or that irritation doesn't cause permanent damage. I could have explained to Connie that sweat and dirt are not the same as Staphylococcus, penicillin-sensitive or not, and that in any event her husband now uses home-cleaned athletic supporters. I might have observed to Ron that irritating your temple in June doesn't leave you with pimples all over your face in September. But there wouldn't have been much point. What is wonderful about patients' self-explanations is both their power and their splendid inconsistency. A certain cream caused a reaction here but not there, now but not then.

Pointing out these contradictions generally doesn't help. Saying, “I've prescribed clindamycin gel for 30 years and I never saw it cause that,” convinces nobody. After all, it happened to me now, didn't it?

Just as they often fail at changing political beliefs, arguments do little to dislodge explanatory models of health and disease. The general principles of these models are easy enough to catalog: Trauma causes irritation, irritation causes permanent damage, dirt causes infection, and so on.

My own conviction, in and out of the office, is that arguing to win a point is a waste of breath. The only times I try to counter, or at least adjust, patients' health beliefs are when holding on to these beliefs will make their lives worse or more complicated than necessary, or when the patients blame their problems on me.

Examples of the former are patients who stop a crucial medicine because they think their rash or hair loss is a reaction to it, who stop exercising because they've read it aggravates rosacea, or who won't polish their nails because they think polish will seal in the fungus infection they don't have. Examples of the latter are the Rons of this world to whom I prescribed tretinoin. (“Well, of course I got this rash from tretinoin, doctor. I never had the rash before, did I?”)

Although debates are sometimes worth having, they are still hard to win. Often the best you can do is negotiate a compromise. (“OK, we won't use tretinoin, we'll use adapalene.”) When the stakes are higher (“You scarred me for life, you bum!”), it's time to call your insurer.

I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”

“No, it won't scar or leave a hole.”

“Will it leave a scar or a hole?”

“No. No scar or hole.”

“Will it leave a scar or a hole?”

“No scar. No hole.”

Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.

Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.

Anxiety is a great promoter of obsession.

“This spot is changing. Is it cancer?”

“No, it isn't cancer.”

“It's not cancer?”

“It's not cancer.”

“Are you sure it's not cancer?”

By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.

Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.

“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”

“No, Ma, just on this one.”

“Why not take off your other shoe, just to check.”

“There aren't any on the other foot. I looked.”

“We're at the doctor's. Let's take a look, to be sure.”

“Ma!”

Some day Samantha will get her chance to pay this forward.

Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.

Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”

Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.

“It's on my back somewhere.”

“Let's see. I'm looking at your whole back, and everything looks fine.”

“But wait, it's here somewhere. …”

If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:

“I'm looking at it. … I can see it. … And it's okay.”

Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)

Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.

Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.

When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.

Ah, blessed relief.

Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.

That's what I think, anyhow.

So what do you think?

So what do you think?

So what do you think?

I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”

“No, it won't scar or leave a hole.”

“Will it leave a scar or a hole?”

“No. No scar or hole.”

“Will it leave a scar or a hole?”

“No scar. No hole.”

Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.

Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.

Anxiety is a great promoter of obsession.

“This spot is changing. Is it cancer?”

“No, it isn't cancer.”

“It's not cancer?”

“It's not cancer.”

“Are you sure it's not cancer?”

By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.

Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.

“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”

“No, Ma, just on this one.”

“Why not take off your other shoe, just to check.”

“There aren't any on the other foot. I looked.”

“We're at the doctor's. Let's take a look, to be sure.”

“Ma!”

Some day Samantha will get her chance to pay this forward.

Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.

Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”

Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.

“It's on my back somewhere.”

“Let's see. I'm looking at your whole back, and everything looks fine.”

“But wait, it's here somewhere. …”

If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:

“I'm looking at it. … I can see it. … And it's okay.”

Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)

Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.

Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.

When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.

Ah, blessed relief.

Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.

That's what I think, anyhow.

So what do you think?

So what do you think?

So what do you think?

I was about to desiccate some small keratoses on Edwin's face. “Will this scar, Doctor? Will it leave a hole?”

“No, it won't scar or leave a hole.”

“Will it leave a scar or a hole?”

“No. No scar or hole.”

“Will it leave a scar or a hole?”

“No scar. No hole.”

Obsessive patients present a challenge. It's hard to answer the same question over and over without being tempted to slug the questioner. This impulse, of course, should be resisted.

Because of the kind of work we do, dermatologists encounter obsessive behavior rather often, whether or not it rises to the level of clinical OCD. Its roots can be the patient's anxiety, social role, or personal style.

Anxiety is a great promoter of obsession.

“This spot is changing. Is it cancer?”

“No, it isn't cancer.”

“It's not cancer?”

“It's not cancer.”

“Are you sure it's not cancer?”

By this point we may be wondering how sure we are, but we can't very well say, “Well, okay, maybe it is cancer,” without losing a certain amount of credibility.

Then there is the social role, specifically the maternal one. Mothers feel that they are required to make sure no stone is left unturned, for fear that later one of the stones will turn out to have something under it. This leads to familiar family minidramas.

“Samantha, please take off your shoe and show the doctor your warts. Do you have some on the other foot, Samantha?”

“No, Ma, just on this one.”

“Why not take off your other shoe, just to check.”

“There aren't any on the other foot. I looked.”

“We're at the doctor's. Let's take a look, to be sure.”

“Ma!”

Some day Samantha will get her chance to pay this forward.

Then there is personal style. It's beyond my competence to decide which of these patients deserve the diagnostic label of OCD, just as I am unsure how many people who admit to washing their hands 10 or 15 times a day are more than just fastidious. In any case, obsessive style can show itself in list-making, whether of complaints or spots.

Our hearts sink, of course, at the sight of a meticulous list of concerns. “I wrote down my questions, Doctor, so I won't forget any.”

Questions on lists are best addressed individually and in order. Any deviation means having to start over. (“Wait, did we do this one yet?”) This is especially true when the list contains specific spots to look at. Each listed spot must be noted and addressed individually. Global evaluations will not do.

“It's on my back somewhere.”

“Let's see. I'm looking at your whole back, and everything looks fine.”

“But wait, it's here somewhere. …”

If the patient is sufficiently anxious or obsessional, I resort to what I call “the OCD three-step.” I touch the spot, pause, and say:

“I'm looking at it. … I can see it. … And it's okay.”

Only then may I move on to the next spot. Any change in sequence or cadence means having to start over. (“Wait, did you see it?”)

Once they finger a spot, patients tend to fondle it lovingly—and at length—making it necessary to gently suggest that they move their opaque digit out of the way.

Sometimes, of course, my patients cannot find the thing that worries them, especially when it is on a hard-to-visualize area like the scalp. If there is something more maddening than watching someone palpate himself with increasingly desperate and furious futility, I don't know what it is.

When this happens, I politely excuse myself and leave the room, explaining that identifying the spot will be much easier when I'm not standing there making everyone nervous. Then I return a couple of minutes later to find the beaming patient with his index finger affixed to his noggin. “I found it!” he exclaims.

Ah, blessed relief.

Compared with our colleagues who may have to address complex medical issues, we have a pretty easy time of it overall. Dealing with obsessive behavior can be a challenge, but it's generally manageable as long as we don't get two or three such patients in a row. That circumstance calls for some form of tension relief, perhaps a glass of something or other after hours.

That's what I think, anyhow.

So what do you think?

So what do you think?

So what do you think?

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

My first contact with Denise was a ringing beeper at 4:30 a.m. “My acne is out of control,” her voice mail message said. “The antibiotic I'm on isn't helping. I get to work at 5:30.”

Predawn acne? I held off till 7 before getting back to her. When she came in later that week, Denise showed me some pretty awful cystic acne, with lakes of pus running under her cheeks and rivers of tears coursing over them. We agreed on isotretinoin as the best treatment. What followed was more weeping, lots of questions (“Why can't I start now?” “When will it start working?”), many phone calls and extra visits for intralesional steroids, and still more questions (“Why isn't it working yet?”).

Four months later, not only is Denise's face remarkably clear but her manner is utterly different. She's calm and reasonable, with no more emotional outbursts. I hardly recognize her.

Recently, I saw another young woman, Marianne, who described an odd history of intermittent showers of papulonodules. Dermatologists hadn't been able to offer a specific diagnosis but reassured her that it didn't have systemic implications. Then she saw a new primary care physician, who told her the rashes were “a serious infection.” This caused much agitation, especially because her job as a nurse in a neonatal ICU made the possibility of transmitting this “infection” a major concern. (In fact, her supervisors banished her from the unit until she got dermatologic clearance.)

Like Denise, Marianne presented with impressive lesions and many tears. Assurance that no infection could produce lesions like hers off and on for years did little to calm her down. A skin biopsy, predictably enough, was nonspecific, consistent as usual with arthropod bites and other entities that were not clinically relevant.

A week after her first visit, though, she returned both clear skinned and calm. Reassurance had sunk in that she was indeed not Typhoid Marianne and that she could keep her job. She was so composed that she too was almost unrecognizable from the week before.

As the adage goes, you don't get a second chance to make a first impression. Many patients are anxious at a first visit, but most don't present with uncontrollable sobbing (or midnight pages). When Denise and Marianne did introduce themselves this way, I had to wonder about their mental stability. After all, I hadn't met them before and so had no way of knowing what they were really like. At first, I had doubts about whether I ought to be treating Denise with isotretinoin. Seeing both women after they had calmed down gave me a chance to reconsider my first impressions and realize that they had been not so much unstable as distraught.

In other social situations, we may choose not to bother reconsidering first impressions. If someone acts unpleasant at a dinner party, we don't invite them back. If they make us uncomfortable at a job interview, we don't hire them. That's why people spend so much time and effort on haircuts, makeup, tooth whitening, and interview coaching to ensure that they'll get the chance to make a second impression.

In many medical interactions, we do get to see people again, whether or not we liked them the first time (though heaven knows we may wish we didn't have to).

Sometimes this helps us realize that our first impressions were wrong. There's the fellow who attacks you for keeping him waiting or the woman who berates the receptionist for taking someone else first or for asking to update demographics or insurance information. Maybe they really are aggressive, obnoxious people. Or maybe they're just scared, convinced they have cancer or leprosy. Once they find out that they don't, their manner might change altogether. Sometimes they even apologize.

It's only natural for us to form a judgment about the patients we meet, especially when their behavior lies outside the range of what experience has taught us to expect. Still, it's helpful to leave mental room to reconsider first impressions and to be willing to put greater stock in second or third ones. When the shoe is on the other foot, we will hope for no less.

“I found you on Yelp,” said Erica. “You had the second most reviews.”

“Saw Dr. Rockoff and was extremely disappointed. … The first time I visited, I was put on a very aggressive treatment plan which ended up not helping my skin problems. When I went back for a follow up, he recommended the same products insisting that I had not tried them yet … when he himself had prescribed them to me 2 months earlier!” Kristen Z.

I looked at Kristen's chart. The “very aggressive” plan was benzoyl peroxide, clindamycin gel, and minocycline. She had used doxycycline, tretinoin, and adapalene for years. At her return visit, I added tazarotene. A month later, she called for refills.

Pretty sharp and accurate review, yes?

Other notices were more favorable. Here's one:

“I go to the Rockoff Center for all my facial needs. This is a dermatologist office, so it is much better than going to a spa.”

So, I guess all that medical school was worth it after all.

But Yelp doesn't limit itself to dermatologists, or even to physicians. You can also read reviews of restaurants, shopping, nightlife, and beauty and spas. In the last category, here's one for a tattoo parlor: “I was so happy with how it came out. It is really simple, just tracing my handwriting, but every day I am amazed at how authentic it looks!”

Sites like Yelp represent a larger cultural trend fostered by the Internet, which lets anyone anywhere say anything to everyone everywhere. In this respect, the Internet is a great leveler that sweeps away rank and privilege and lets professors and peons alike hold forth on history, medicine, or fast-food joints. Those who choose to can show the universe their picture; share their birthdays, hobbies, and preferences; and let the world read more about them.

The effects of this trend are still evolving, but they are likely to be profound and may have increasing relevance to physicians. Consumer Aware and Blue Cross Blue Shield of Minnesota have set up a Yelp-like site, www.thehealthcarescoop.com

“My daughter died of heart failure at the [XYZ] Heart Hospital. [She] had an aortic valve replacement. … She was 28 when she went in for her aftercare checkup with the surgeon, she died a day later in the hospital. The medical team assigned to her, as well as her surgeon, did not respond with any urgency even though there was an infection present, she was given no antibiotics. … Hindsight tells me that she would be alive today had the proper care been taken at the time she came in for her aftercare checkup.”

Here's another: “My wife was scheduled for her first colonoscopy so she was naturally nervous. The staff at the [ABC] Clinic made her feel very comfortable. They were very attentive during the recovery time and even followed up with a 'check-in' phone call after the procedure to see how she was doing. The [ABC] Clinic is great.”

Is XYZ Heart Hospital incompetent? Is ABC Clinic superb? “Reviews” like these give us no real idea. Those who write them are, of course, entitled to their opinions, and the nature of such opinions give us insight into the way real people—our patients—talk about us to their friends and family and judge how we've done.

But should society rate us on the basis of reviews of this kind? Will this become yet another flawed criterion that health insurers will use to implement pay for performance?

Maybe we should call our leaders and professional societies and do some yelping ourselves.

“I found you on Yelp,” said Erica. “You had the second most reviews.”

“Saw Dr. Rockoff and was extremely disappointed. … The first time I visited, I was put on a very aggressive treatment plan which ended up not helping my skin problems. When I went back for a follow up, he recommended the same products insisting that I had not tried them yet … when he himself had prescribed them to me 2 months earlier!” Kristen Z.

I looked at Kristen's chart. The “very aggressive” plan was benzoyl peroxide, clindamycin gel, and minocycline. She had used doxycycline, tretinoin, and adapalene for years. At her return visit, I added tazarotene. A month later, she called for refills.

Pretty sharp and accurate review, yes?

Other notices were more favorable. Here's one:

“I go to the Rockoff Center for all my facial needs. This is a dermatologist office, so it is much better than going to a spa.”

So, I guess all that medical school was worth it after all.

But Yelp doesn't limit itself to dermatologists, or even to physicians. You can also read reviews of restaurants, shopping, nightlife, and beauty and spas. In the last category, here's one for a tattoo parlor: “I was so happy with how it came out. It is really simple, just tracing my handwriting, but every day I am amazed at how authentic it looks!”

Sites like Yelp represent a larger cultural trend fostered by the Internet, which lets anyone anywhere say anything to everyone everywhere. In this respect, the Internet is a great leveler that sweeps away rank and privilege and lets professors and peons alike hold forth on history, medicine, or fast-food joints. Those who choose to can show the universe their picture; share their birthdays, hobbies, and preferences; and let the world read more about them.

The effects of this trend are still evolving, but they are likely to be profound and may have increasing relevance to physicians. Consumer Aware and Blue Cross Blue Shield of Minnesota have set up a Yelp-like site, www.thehealthcarescoop.com

“My daughter died of heart failure at the [XYZ] Heart Hospital. [She] had an aortic valve replacement. … She was 28 when she went in for her aftercare checkup with the surgeon, she died a day later in the hospital. The medical team assigned to her, as well as her surgeon, did not respond with any urgency even though there was an infection present, she was given no antibiotics. … Hindsight tells me that she would be alive today had the proper care been taken at the time she came in for her aftercare checkup.”

Here's another: “My wife was scheduled for her first colonoscopy so she was naturally nervous. The staff at the [ABC] Clinic made her feel very comfortable. They were very attentive during the recovery time and even followed up with a 'check-in' phone call after the procedure to see how she was doing. The [ABC] Clinic is great.”

Is XYZ Heart Hospital incompetent? Is ABC Clinic superb? “Reviews” like these give us no real idea. Those who write them are, of course, entitled to their opinions, and the nature of such opinions give us insight into the way real people—our patients—talk about us to their friends and family and judge how we've done.

But should society rate us on the basis of reviews of this kind? Will this become yet another flawed criterion that health insurers will use to implement pay for performance?

Maybe we should call our leaders and professional societies and do some yelping ourselves.

“I found you on Yelp,” said Erica. “You had the second most reviews.”

“Saw Dr. Rockoff and was extremely disappointed. … The first time I visited, I was put on a very aggressive treatment plan which ended up not helping my skin problems. When I went back for a follow up, he recommended the same products insisting that I had not tried them yet … when he himself had prescribed them to me 2 months earlier!” Kristen Z.

I looked at Kristen's chart. The “very aggressive” plan was benzoyl peroxide, clindamycin gel, and minocycline. She had used doxycycline, tretinoin, and adapalene for years. At her return visit, I added tazarotene. A month later, she called for refills.

Pretty sharp and accurate review, yes?

Other notices were more favorable. Here's one:

“I go to the Rockoff Center for all my facial needs. This is a dermatologist office, so it is much better than going to a spa.”

So, I guess all that medical school was worth it after all.

But Yelp doesn't limit itself to dermatologists, or even to physicians. You can also read reviews of restaurants, shopping, nightlife, and beauty and spas. In the last category, here's one for a tattoo parlor: “I was so happy with how it came out. It is really simple, just tracing my handwriting, but every day I am amazed at how authentic it looks!”

Sites like Yelp represent a larger cultural trend fostered by the Internet, which lets anyone anywhere say anything to everyone everywhere. In this respect, the Internet is a great leveler that sweeps away rank and privilege and lets professors and peons alike hold forth on history, medicine, or fast-food joints. Those who choose to can show the universe their picture; share their birthdays, hobbies, and preferences; and let the world read more about them.

The effects of this trend are still evolving, but they are likely to be profound and may have increasing relevance to physicians. Consumer Aware and Blue Cross Blue Shield of Minnesota have set up a Yelp-like site, www.thehealthcarescoop.com

“My daughter died of heart failure at the [XYZ] Heart Hospital. [She] had an aortic valve replacement. … She was 28 when she went in for her aftercare checkup with the surgeon, she died a day later in the hospital. The medical team assigned to her, as well as her surgeon, did not respond with any urgency even though there was an infection present, she was given no antibiotics. … Hindsight tells me that she would be alive today had the proper care been taken at the time she came in for her aftercare checkup.”

Here's another: “My wife was scheduled for her first colonoscopy so she was naturally nervous. The staff at the [ABC] Clinic made her feel very comfortable. They were very attentive during the recovery time and even followed up with a 'check-in' phone call after the procedure to see how she was doing. The [ABC] Clinic is great.”

Is XYZ Heart Hospital incompetent? Is ABC Clinic superb? “Reviews” like these give us no real idea. Those who write them are, of course, entitled to their opinions, and the nature of such opinions give us insight into the way real people—our patients—talk about us to their friends and family and judge how we've done.

But should society rate us on the basis of reviews of this kind? Will this become yet another flawed criterion that health insurers will use to implement pay for performance?

Maybe we should call our leaders and professional societies and do some yelping ourselves.

On Wednesday, little Esmeralda's eczema took a turn for the worse. "It's infected," I told her mother, "so I'm prescribing this antibiotic syrup and topical cream. Here is my private extension. I need you to call me first thing Friday morning so I'll know how she's doing before the long weekend."

No message was waiting Friday, so I called at 9 a.m. and left one myself. I left another at noon. As I was preparing to leave at 2 p.m., Esmeralda's mother called, not to tell me that her daughter was improving, which she was, but to ask me to fax a report to Esmeralda's day care providers. I offered to call instead. "No," she said, "I need you to fax them what you recommended."

That same Wednesday, I got a call from a pulmonologist. A mutual patient, Fishbane, had come down with tuberculosis but was itching like crazy and refusing to take his medications. He needed to see me at once, but I was in my other office and he wouldn't come there. Could I see him Thursday? Sure. Arrangements were made, with thanks for my being so helpful. Fishbane never showed.

All this is familiar, of course: Patients follow through when it suits their needs.

"Hi, Henry. It's been 5 years. Are you back because you had that squamous cell, and I asked you to come annually?"

"Oh no, Doc. I have this new spot I'm worried about."

Nonhermits have many kinds of relationships. These relationships involve needs that each party satisfies to some extent. In the doctor-patient relationship, patients need us to diagnose correctly, prescribe properly, and behave with courtesy. We need them to show up, call back, and either cooperate with treatment or at least let us know why they can't.

Relationships flourish when people make allowances, but they founder when needs, duties, and shortcomings are aggressively spelled out.

"I've been waiting an hour," hissed Spencer. "I'm a professional like you, and I too have other appointments. It's clear that you care only about your own needs, not mine."

Maybe Spencer is just having a bad day, but suppose he's always like that. Imagine being married to him. His complaint is not without merit, but I have needs too. Spencer wants to get on with his day. I want to stay busy even when some patients don't show, others come late, and still others must be fit in right away (or, like Fishbane, claim they do).

Most of us know we'll get only some of what we need and decide to muddle through. Patients expect to wait a while. Doctors know that many patients won't remember which treatments didn't work. Some people, though, aren't satisfied with muddling and demand precision: yes or no, right or wrong, exactly how many minutes' wait is too many. That's how lawyers and bureaucrats think—an approach useful in its place but toxic to ordinary relationships, which are rife with fuzziness and ambiguity. Think of the difference between the arrangements a husband and wife make to pick up their kids versus those dictated by a divorce court.

"Thanks for taking off my wart, doctor," says Sue. "Would it be okay if I asked you one more question?" Well, sure, especially since you're asking so nicely.

But what about Phyllis, who has nine separate issues to discuss with magisterial deliberation and a sense of serene entitlement, and who catches you at the door trying to escape with, "And oh yes, doctor, my hair is falling out"?

How many questions does Phyllis have a right to ask? One? Three? Six from column A and two from column B? She needs to have her concerns addressed, but I have needs too. I need to get the heck out and see another patient. Sue is very considerate, but now and then the office serves up a Phyllis, just as life brings us bores who won't shut up or guests who won't leave.

Most people are considerate; others are endlessly needy. One way or another, we negotiate needs all day long. Considering how many people we deal with every day, it's a wonder how well things usually go. Sometimes a Phyllis or two shows up and throws things off. Then we can go home and crack open a beer. Whack a golf ball. Write a column.

On Wednesday, little Esmeralda's eczema took a turn for the worse. "It's infected," I told her mother, "so I'm prescribing this antibiotic syrup and topical cream. Here is my private extension. I need you to call me first thing Friday morning so I'll know how she's doing before the long weekend."

No message was waiting Friday, so I called at 9 a.m. and left one myself. I left another at noon. As I was preparing to leave at 2 p.m., Esmeralda's mother called, not to tell me that her daughter was improving, which she was, but to ask me to fax a report to Esmeralda's day care providers. I offered to call instead. "No," she said, "I need you to fax them what you recommended."

That same Wednesday, I got a call from a pulmonologist. A mutual patient, Fishbane, had come down with tuberculosis but was itching like crazy and refusing to take his medications. He needed to see me at once, but I was in my other office and he wouldn't come there. Could I see him Thursday? Sure. Arrangements were made, with thanks for my being so helpful. Fishbane never showed.

All this is familiar, of course: Patients follow through when it suits their needs.

"Hi, Henry. It's been 5 years. Are you back because you had that squamous cell, and I asked you to come annually?"

"Oh no, Doc. I have this new spot I'm worried about."

Nonhermits have many kinds of relationships. These relationships involve needs that each party satisfies to some extent. In the doctor-patient relationship, patients need us to diagnose correctly, prescribe properly, and behave with courtesy. We need them to show up, call back, and either cooperate with treatment or at least let us know why they can't.

Relationships flourish when people make allowances, but they founder when needs, duties, and shortcomings are aggressively spelled out.

"I've been waiting an hour," hissed Spencer. "I'm a professional like you, and I too have other appointments. It's clear that you care only about your own needs, not mine."

Maybe Spencer is just having a bad day, but suppose he's always like that. Imagine being married to him. His complaint is not without merit, but I have needs too. Spencer wants to get on with his day. I want to stay busy even when some patients don't show, others come late, and still others must be fit in right away (or, like Fishbane, claim they do).

Most of us know we'll get only some of what we need and decide to muddle through. Patients expect to wait a while. Doctors know that many patients won't remember which treatments didn't work. Some people, though, aren't satisfied with muddling and demand precision: yes or no, right or wrong, exactly how many minutes' wait is too many. That's how lawyers and bureaucrats think—an approach useful in its place but toxic to ordinary relationships, which are rife with fuzziness and ambiguity. Think of the difference between the arrangements a husband and wife make to pick up their kids versus those dictated by a divorce court.

"Thanks for taking off my wart, doctor," says Sue. "Would it be okay if I asked you one more question?" Well, sure, especially since you're asking so nicely.

But what about Phyllis, who has nine separate issues to discuss with magisterial deliberation and a sense of serene entitlement, and who catches you at the door trying to escape with, "And oh yes, doctor, my hair is falling out"?

How many questions does Phyllis have a right to ask? One? Three? Six from column A and two from column B? She needs to have her concerns addressed, but I have needs too. I need to get the heck out and see another patient. Sue is very considerate, but now and then the office serves up a Phyllis, just as life brings us bores who won't shut up or guests who won't leave.

Most people are considerate; others are endlessly needy. One way or another, we negotiate needs all day long. Considering how many people we deal with every day, it's a wonder how well things usually go. Sometimes a Phyllis or two shows up and throws things off. Then we can go home and crack open a beer. Whack a golf ball. Write a column.

On Wednesday, little Esmeralda's eczema took a turn for the worse. "It's infected," I told her mother, "so I'm prescribing this antibiotic syrup and topical cream. Here is my private extension. I need you to call me first thing Friday morning so I'll know how she's doing before the long weekend."

No message was waiting Friday, so I called at 9 a.m. and left one myself. I left another at noon. As I was preparing to leave at 2 p.m., Esmeralda's mother called, not to tell me that her daughter was improving, which she was, but to ask me to fax a report to Esmeralda's day care providers. I offered to call instead. "No," she said, "I need you to fax them what you recommended."

That same Wednesday, I got a call from a pulmonologist. A mutual patient, Fishbane, had come down with tuberculosis but was itching like crazy and refusing to take his medications. He needed to see me at once, but I was in my other office and he wouldn't come there. Could I see him Thursday? Sure. Arrangements were made, with thanks for my being so helpful. Fishbane never showed.

All this is familiar, of course: Patients follow through when it suits their needs.

"Hi, Henry. It's been 5 years. Are you back because you had that squamous cell, and I asked you to come annually?"

"Oh no, Doc. I have this new spot I'm worried about."

Nonhermits have many kinds of relationships. These relationships involve needs that each party satisfies to some extent. In the doctor-patient relationship, patients need us to diagnose correctly, prescribe properly, and behave with courtesy. We need them to show up, call back, and either cooperate with treatment or at least let us know why they can't.

Relationships flourish when people make allowances, but they founder when needs, duties, and shortcomings are aggressively spelled out.

"I've been waiting an hour," hissed Spencer. "I'm a professional like you, and I too have other appointments. It's clear that you care only about your own needs, not mine."

Maybe Spencer is just having a bad day, but suppose he's always like that. Imagine being married to him. His complaint is not without merit, but I have needs too. Spencer wants to get on with his day. I want to stay busy even when some patients don't show, others come late, and still others must be fit in right away (or, like Fishbane, claim they do).

Most of us know we'll get only some of what we need and decide to muddle through. Patients expect to wait a while. Doctors know that many patients won't remember which treatments didn't work. Some people, though, aren't satisfied with muddling and demand precision: yes or no, right or wrong, exactly how many minutes' wait is too many. That's how lawyers and bureaucrats think—an approach useful in its place but toxic to ordinary relationships, which are rife with fuzziness and ambiguity. Think of the difference between the arrangements a husband and wife make to pick up their kids versus those dictated by a divorce court.

"Thanks for taking off my wart, doctor," says Sue. "Would it be okay if I asked you one more question?" Well, sure, especially since you're asking so nicely.

But what about Phyllis, who has nine separate issues to discuss with magisterial deliberation and a sense of serene entitlement, and who catches you at the door trying to escape with, "And oh yes, doctor, my hair is falling out"?

How many questions does Phyllis have a right to ask? One? Three? Six from column A and two from column B? She needs to have her concerns addressed, but I have needs too. I need to get the heck out and see another patient. Sue is very considerate, but now and then the office serves up a Phyllis, just as life brings us bores who won't shut up or guests who won't leave.

Most people are considerate; others are endlessly needy. One way or another, we negotiate needs all day long. Considering how many people we deal with every day, it's a wonder how well things usually go. Sometimes a Phyllis or two shows up and throws things off. Then we can go home and crack open a beer. Whack a golf ball. Write a column.

When I started my practice, patients found me through the Yellow Pages. “I recognized your address,” they said, or “You were convenient.” It seemed a little impersonal, but what could I expect? I was new.

Later, patients found me on HMO lists. Their physicians referred them because I was the only dermatologist on the rosters at the time, my older colleagues having refused to join. I dutifully sent referral letters to physicians I didn't know: “Dear Doctor: Thank you for referring Jane. I am treating her acne with such-and-such.” Perhaps they read them.

As my fame and reputation grew, I began getting referrals from doctors' receptionists. “They gave me a list,” patients would say.” 'Here are the three dermatologists we use.' The lady at the front desk suggested you.” An article I once wrote for a medical magazine was titled, “My Doctor's Receptionist's Hairdresser Sent Me Over.”

I understood all this. Even before our field became synonymous in the public mind with Botox and cosmetic fluff, nondermatologists thought of skin diseases as something exotic and superficial (“It's one of those skin things. Go see a skin guy.”), if not alien and frightening (“Lordy, it's one of those skin things! Go see a skin guy!”).

I could be wrong, but I can't imagine similar referrals to other specialties. (“Your ticker is tocking. Go see a heart guy.”) In any case, even when patients have come from other physicians, I have rarely felt a sense of the real collegiality I imagine takes place in hospital corridors and cafeterias. Once in a great while over the years, I've gotten an urgent call from a doctor in my own building eager to send down a patient with a dramatic rash, and I've even gone upstairs myself while the patient was still with the internist or surgeon. Such occasions have been uniquely satisfying, though rare enough that I can actually remember them.

Now that I've been around for a long time, many of the doctors who used to refer patients to me, one way or another, have retired, slowed down, or gone concierge. Also, more people have PPOs that don't require physician referral. As a result, when I ask, “Who referred you to me?” I'm apt to hear, “I looked you up online on my insurer's Web site, and I recognized your address. You were convenient.” Higher tech, but familiar.

Sometimes people are referred by other people. “I got your name from a friend,” they'll say.

“Neat. Which friend?”

“Uhhh … actually, I think it was my mother-in-law's friend.”

Then of course there's Google. “I did an Internet search,” a new patient says.

“No kidding,” I reply. “What did you search for?”

“Dermatologists in Brookline.”

Makes you feel warm and fuzzy all over, doesn't it?

One patient was more flattering. “I Googled 'Top Dermatologists, Brookline.'”

Wow, I thought. I've been optimized.

I Googled that myself, and what came up first was an Internet Yellow Pages site with a list called “Featured Advertisers: Dermatology” on top, the first of which was an animal hospital, with an offer to “get coupon for pet's first visit!” Next to that was a listing for a (human) dermatologist in a town 20 miles north. Scrolling down past more advertisers and a long paragraph of skin-related keywords, I found actual dermatologists in Brookline. I came in second, with an incorrect address.

Just for fun, I Googled “Bottom Dermatologist Brookline.” The top listing for that was an answer on a medical Web site that I wrote in 2005 to a worried questioner who had pimples on his bottom. Bottom's up!

Not long ago, I saw a patient who identified herself as a “health writer for the Wall Street Journal.” After I examined her, she asked me for the name of an internist. “I need someone affiliated with a major teaching hospital,” she explained. “In case I get sick, I need access to the most advanced medical care. I'm a sophisticated medical consumer,” she added. “After all, I'm a health writer for the Wall Street Journal.”

I gave her the names of two doctors. “By the way,” I asked her, “how did you find me?”

“The mailman,” she said. “I met him while I was walking by your building, and he told me he hears you're good.”

Well, I am the only dermatologist in the building.

When I started my practice, patients found me through the Yellow Pages. “I recognized your address,” they said, or “You were convenient.” It seemed a little impersonal, but what could I expect? I was new.

Later, patients found me on HMO lists. Their physicians referred them because I was the only dermatologist on the rosters at the time, my older colleagues having refused to join. I dutifully sent referral letters to physicians I didn't know: “Dear Doctor: Thank you for referring Jane. I am treating her acne with such-and-such.” Perhaps they read them.

As my fame and reputation grew, I began getting referrals from doctors' receptionists. “They gave me a list,” patients would say.” 'Here are the three dermatologists we use.' The lady at the front desk suggested you.” An article I once wrote for a medical magazine was titled, “My Doctor's Receptionist's Hairdresser Sent Me Over.”

I understood all this. Even before our field became synonymous in the public mind with Botox and cosmetic fluff, nondermatologists thought of skin diseases as something exotic and superficial (“It's one of those skin things. Go see a skin guy.”), if not alien and frightening (“Lordy, it's one of those skin things! Go see a skin guy!”).

I could be wrong, but I can't imagine similar referrals to other specialties. (“Your ticker is tocking. Go see a heart guy.”) In any case, even when patients have come from other physicians, I have rarely felt a sense of the real collegiality I imagine takes place in hospital corridors and cafeterias. Once in a great while over the years, I've gotten an urgent call from a doctor in my own building eager to send down a patient with a dramatic rash, and I've even gone upstairs myself while the patient was still with the internist or surgeon. Such occasions have been uniquely satisfying, though rare enough that I can actually remember them.

Now that I've been around for a long time, many of the doctors who used to refer patients to me, one way or another, have retired, slowed down, or gone concierge. Also, more people have PPOs that don't require physician referral. As a result, when I ask, “Who referred you to me?” I'm apt to hear, “I looked you up online on my insurer's Web site, and I recognized your address. You were convenient.” Higher tech, but familiar.

Sometimes people are referred by other people. “I got your name from a friend,” they'll say.

“Neat. Which friend?”

“Uhhh … actually, I think it was my mother-in-law's friend.”

Then of course there's Google. “I did an Internet search,” a new patient says.

“No kidding,” I reply. “What did you search for?”

“Dermatologists in Brookline.”

Makes you feel warm and fuzzy all over, doesn't it?

One patient was more flattering. “I Googled 'Top Dermatologists, Brookline.'”

Wow, I thought. I've been optimized.

I Googled that myself, and what came up first was an Internet Yellow Pages site with a list called “Featured Advertisers: Dermatology” on top, the first of which was an animal hospital, with an offer to “get coupon for pet's first visit!” Next to that was a listing for a (human) dermatologist in a town 20 miles north. Scrolling down past more advertisers and a long paragraph of skin-related keywords, I found actual dermatologists in Brookline. I came in second, with an incorrect address.

Just for fun, I Googled “Bottom Dermatologist Brookline.” The top listing for that was an answer on a medical Web site that I wrote in 2005 to a worried questioner who had pimples on his bottom. Bottom's up!

Not long ago, I saw a patient who identified herself as a “health writer for the Wall Street Journal.” After I examined her, she asked me for the name of an internist. “I need someone affiliated with a major teaching hospital,” she explained. “In case I get sick, I need access to the most advanced medical care. I'm a sophisticated medical consumer,” she added. “After all, I'm a health writer for the Wall Street Journal.”

I gave her the names of two doctors. “By the way,” I asked her, “how did you find me?”

“The mailman,” she said. “I met him while I was walking by your building, and he told me he hears you're good.”

Well, I am the only dermatologist in the building.

When I started my practice, patients found me through the Yellow Pages. “I recognized your address,” they said, or “You were convenient.” It seemed a little impersonal, but what could I expect? I was new.

Later, patients found me on HMO lists. Their physicians referred them because I was the only dermatologist on the rosters at the time, my older colleagues having refused to join. I dutifully sent referral letters to physicians I didn't know: “Dear Doctor: Thank you for referring Jane. I am treating her acne with such-and-such.” Perhaps they read them.

As my fame and reputation grew, I began getting referrals from doctors' receptionists. “They gave me a list,” patients would say.” 'Here are the three dermatologists we use.' The lady at the front desk suggested you.” An article I once wrote for a medical magazine was titled, “My Doctor's Receptionist's Hairdresser Sent Me Over.”

I understood all this. Even before our field became synonymous in the public mind with Botox and cosmetic fluff, nondermatologists thought of skin diseases as something exotic and superficial (“It's one of those skin things. Go see a skin guy.”), if not alien and frightening (“Lordy, it's one of those skin things! Go see a skin guy!”).

I could be wrong, but I can't imagine similar referrals to other specialties. (“Your ticker is tocking. Go see a heart guy.”) In any case, even when patients have come from other physicians, I have rarely felt a sense of the real collegiality I imagine takes place in hospital corridors and cafeterias. Once in a great while over the years, I've gotten an urgent call from a doctor in my own building eager to send down a patient with a dramatic rash, and I've even gone upstairs myself while the patient was still with the internist or surgeon. Such occasions have been uniquely satisfying, though rare enough that I can actually remember them.

Now that I've been around for a long time, many of the doctors who used to refer patients to me, one way or another, have retired, slowed down, or gone concierge. Also, more people have PPOs that don't require physician referral. As a result, when I ask, “Who referred you to me?” I'm apt to hear, “I looked you up online on my insurer's Web site, and I recognized your address. You were convenient.” Higher tech, but familiar.

Sometimes people are referred by other people. “I got your name from a friend,” they'll say.

“Neat. Which friend?”

“Uhhh … actually, I think it was my mother-in-law's friend.”

Then of course there's Google. “I did an Internet search,” a new patient says.

“No kidding,” I reply. “What did you search for?”

“Dermatologists in Brookline.”

Makes you feel warm and fuzzy all over, doesn't it?

One patient was more flattering. “I Googled 'Top Dermatologists, Brookline.'”

Wow, I thought. I've been optimized.

I Googled that myself, and what came up first was an Internet Yellow Pages site with a list called “Featured Advertisers: Dermatology” on top, the first of which was an animal hospital, with an offer to “get coupon for pet's first visit!” Next to that was a listing for a (human) dermatologist in a town 20 miles north. Scrolling down past more advertisers and a long paragraph of skin-related keywords, I found actual dermatologists in Brookline. I came in second, with an incorrect address.

Just for fun, I Googled “Bottom Dermatologist Brookline.” The top listing for that was an answer on a medical Web site that I wrote in 2005 to a worried questioner who had pimples on his bottom. Bottom's up!

Not long ago, I saw a patient who identified herself as a “health writer for the Wall Street Journal.” After I examined her, she asked me for the name of an internist. “I need someone affiliated with a major teaching hospital,” she explained. “In case I get sick, I need access to the most advanced medical care. I'm a sophisticated medical consumer,” she added. “After all, I'm a health writer for the Wall Street Journal.”

I gave her the names of two doctors. “By the way,” I asked her, “how did you find me?”

“The mailman,” she said. “I met him while I was walking by your building, and he told me he hears you're good.”

Well, I am the only dermatologist in the building.

“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”

Silence.

“Has the clindamycin lotion in the morning helped with dryness?”

Silence.

“How often do you put the creams on?”

Silence.

It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.

“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”

Silence.

“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”

Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.

The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?

Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.

These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:

P Never give an adolescent male more than two things to do.

P Ask for twice a day, hope for once.

P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.

When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”

In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.

Well, I can dream, can't I?

Those who analyze nonadherence point out factors that contribute to it or might help counter it.

The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.

Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?

I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?

Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.

“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”

Silence.

“Has the clindamycin lotion in the morning helped with dryness?”

Silence.

“How often do you put the creams on?”

Silence.

It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.

“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”

Silence.

“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”

Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.

The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?

Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.

These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:

P Never give an adolescent male more than two things to do.

P Ask for twice a day, hope for once.

P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.

When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”

In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.

Well, I can dream, can't I?

Those who analyze nonadherence point out factors that contribute to it or might help counter it.

The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.

Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?

I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?

Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.

“Your acne seems worse than 6 months ago, Holly. Are you using the tretinoin every night?”

Silence.

“Has the clindamycin lotion in the morning helped with dryness?”

Silence.

“How often do you put the creams on?”

Silence.

It seems Holly has been applying tretinoin once or twice a week—maybe—and the clindamycin not at all.

“Holly, is that because you didn't have the time, or was the medicine giving you side effects?”

Silence.

“Well, I guess if you haven't really tried the treatment yet, we don't have to change it!”

Noncompliance is an old story, of course. (The newer term, nonadherence, sounds less authoritarian.) A few recent articles address this issue, one with the charming title, “Adherence to Topical Therapy Increases Around the Time of Office Visits” (J. Am. Acad. Dermatol. 2007;57:81–3). The study authors draw suitable analogies to other behaviors, like flossing before dental visits and practicing before piano lessons. They also provide statistics that jibe with my own clinical impressions: For a cream to be applied 2 times a day for 8 weeks, the average daily application was in fact 1.1.

The same month an editorial, “Poor Adherence to Treatments: A Fundamental Principle of Dermatology,” took up nonadherence in a more comprehensive way (Arch. Dermatol. 2007;143: 912–5). The authors commented on a study published the same month finding that almost half of PUVA patients who switched to biological agents for psoriasis treatment were in worse shape at the time of the switch than one would expect from PUVA's known effectiveness (Arch. Dermatol. 2007;143:846–50). Maybe patients had become disenchanted with PUVA and stopped using it?

Perhaps, they suggest, treatments work better in trials than in real clinical life because in study situations patients actually use them. Tachyphylaxis might have more to do with human behavior than with corticosteroid receptor sensitivity.

These provocative speculations sound plausible. In any case, like any longtime physician, I factor nonadherence into my advice. Examples include the following:

P Never give an adolescent male more than two things to do.

P Ask for twice a day, hope for once.

P Emphasize the need to call about side effects that might make continued use difficult for conditions such as acne.

When I see a patient for follow-up and look at my notes to see what I prescribed, I usually start by asking, “What are you using?” Patients hardly ever challenge me to look at my own chart. Often, they've stopped the medicine weeks or months earlier because of a perceived side effect but didn't call, because “I didn't want to bother you.”

In darker moments, I toy with imagined proadherence tactics like blast e-mails (“IT'S 11 PM. HAVE YOU APPLIED YOUR ADAPALENE?”) or perhaps capsule containers with sensors like the ones they use in drug-compliance studies, only mine would come equipped with stun guns to remind patients, in a generally nonlethal manner, that they've missed too many doses.

Well, I can dream, can't I?

Those who analyze nonadherence point out factors that contribute to it or might help counter it.

The authors of the previously mentioned editorial do this nicely by advising “establishing a strong, trusting physician-patient relationship; choosing vehicles that can fit patients' lifestyles; using patient educational materials designed to motivate without overly stressing risks; and scheduling a follow-up visit shortly after initiating a new treatment.” At the same time, they are quite right to assert, “We are on the verge of understanding that patient noncompliance is a nearly universal principle of dermatologic treatment.” I would disagree only by asking, “Why just dermatologic?” and by adding that we're already over the verge.

Still, accepting this understanding should not exempt us from asking who benefits from proper compliance, and who is harmed by its absence? Before being quick to answer that it's all about patient welfare, consider how nicely the world has been getting along in the face of demonstrated nonadherence on a massive scale. That might be a blow to our professional ego, but is a patient with psoriasis really worse off in the scheme of things if he decides that living with his plaques is less trouble than fighting with them?

I'm too old to expect big changes in human nature. It seems to me that our job as physician-advisers is to let people know their options and the stakes involved if they choose not to exercise them, and to nudge them in the right direction. Then they can do what they want. Which they're going to do anyway, aren't they?

Sorry to run. I'm seeing my dentist tomorrow, and I haven't flossed all week.