Under My Skin

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession—the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy, oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession—the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy, oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession—the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy, oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

Nondermatologists like to mock, "Hey, we know what you guys do: If it's wet, dry it, and if it's dry, wet it."

Most of the students who follow me around are headed for primary care. When I meet a new one, I'm tempted to say, "The goal of this elective is to make sure that, by the time you leave, you won't say, 'If it's eczema, I'll treat it as a fungus, and if it's a fungus, I'll treat it with a steroid.'"

That would be snide and condescending, though, so I stifle the impulse. But then comes a new student, Darlene, and a day like last Thursday. …

Case 1

"Doc, I have this rash between my butt cheeks, and the cream I'm using doesn't help at all."

"Which cream is that?"

"Clotrimazole."

"See the pinkness spanning the cleft?" I show Darlene. "That's inverse psoriasis, so clotrimazole won't work. He needs a steroid."

Case 2

"It's been a week, Fred. How are you?"

"My butt feels much better, Doc. The itch was maddening."

His gluteal cleft looks all clear. A couple of weeks of nystatin-triamcinolone had left him with a nice rim of satellite pustules and a lot of itch. Econazole did the trick.

"He had a yeast infection," I say. "The triamcinolone trumped the nystatin. A straight antiyeast cream is what he needed."

"Isn't that the opposite of the other patient?" Darlene asks.

The kids are so smart these days.

Case 3

"How long has Vince had this scaling on his soles?"

"He's 10, so I guess it's about 6 years."

"And what has his pediatrician recommended?"

"An antifungal cream. It sort of works. After 2 weeks of using it, the scaling is a little better."

"Let's try a different approach. Foot rashes on prepubertal kids are usually eczematous rather than fungal," I explain.

"Why didn't the pediatrician change the prescription?" Darlene asks.

"Probably because the patient didn't complain. The fungus cream is a cream, after all, so it smoothed things down a bit."

"But for 6 years?"

Case 4

Ricardo has a patch of psoriasis peeking out from his right frontal scalp. Nice pink, micaceous scale. Clearly defined outline. Treatment hasn't been working.

"What did you use?"

"My doctor gave me a cream and some pills. I wrote it down—griseofulvin. I took it for a month, but it didn't help."

"Tinea affects the scalp mostly in kids," I tell Darlene, "and Ricardo is 23. Also, tinea causes hair loss, which he doesn't have."

"If it's inflammatory, treat it as a fungus," she says with a sly smile, "and if it's a fungus …"

"You said it," I tell her, "but I thought it."

The Internet Post

Thursday was unusual, but such stories are not. Here's a typical Internet post:

I saw a doctor a couple times because a small lesion appeared near my urethra last September. It's small and doesn't bother me much, but it weeps a clear fluid. It also came along with dry skin/redness on my scrotum, which bothers me occasionally. The doctor told me it was nothing to worry about and it was just a fungus.

What fungus would that be, exactly?

Differentiating an inflammatory dermatosis from a fungus or yeast can be tricky: Scrapings are sometimes unreliable, cultures delayed and overgrown with contaminants.

I confess to my share of "whoops" moments when the sight of spreading, polycyclic lesions on the ankles or neck showed that a topical steroid might not have been such a good idea after all. When it comes to papulosquamous rashes, there are just two basic choices—fungus or not fungus—and two outcomes—better and not better. This isn't rocket science.

Yet, year in and year out, people troop in to show me nummular eczema that their doctors, some even older than I am, have been treating with endless applications of Lamisil (terbinafine) or clotrimazole. The monotony of such cases is relieved only by the occasional unfortunate with Candida or tinea who's never been taken off the triamcinolone or steroid-antifungal combination that's clearly making things worse.

There's a big push these days to rate (and pay) physicians based on their efficient use of evidence-based therapies with reliable outcomes. Here, I suggest, is a good place to start: Train doctors while they're still in school that, wet or dry, if it's a fungus, treat it as one, and if it isn't, don't.

Nondermatologists like to mock, "Hey, we know what you guys do: If it's wet, dry it, and if it's dry, wet it."

Most of the students who follow me around are headed for primary care. When I meet a new one, I'm tempted to say, "The goal of this elective is to make sure that, by the time you leave, you won't say, 'If it's eczema, I'll treat it as a fungus, and if it's a fungus, I'll treat it with a steroid.'"

That would be snide and condescending, though, so I stifle the impulse. But then comes a new student, Darlene, and a day like last Thursday. …

Case 1

"Doc, I have this rash between my butt cheeks, and the cream I'm using doesn't help at all."

"Which cream is that?"

"Clotrimazole."

"See the pinkness spanning the cleft?" I show Darlene. "That's inverse psoriasis, so clotrimazole won't work. He needs a steroid."

Case 2

"It's been a week, Fred. How are you?"

"My butt feels much better, Doc. The itch was maddening."

His gluteal cleft looks all clear. A couple of weeks of nystatin-triamcinolone had left him with a nice rim of satellite pustules and a lot of itch. Econazole did the trick.

"He had a yeast infection," I say. "The triamcinolone trumped the nystatin. A straight antiyeast cream is what he needed."

"Isn't that the opposite of the other patient?" Darlene asks.

The kids are so smart these days.

Case 3

"How long has Vince had this scaling on his soles?"

"He's 10, so I guess it's about 6 years."

"And what has his pediatrician recommended?"

"An antifungal cream. It sort of works. After 2 weeks of using it, the scaling is a little better."

"Let's try a different approach. Foot rashes on prepubertal kids are usually eczematous rather than fungal," I explain.

"Why didn't the pediatrician change the prescription?" Darlene asks.

"Probably because the patient didn't complain. The fungus cream is a cream, after all, so it smoothed things down a bit."

"But for 6 years?"

Case 4

Ricardo has a patch of psoriasis peeking out from his right frontal scalp. Nice pink, micaceous scale. Clearly defined outline. Treatment hasn't been working.

"What did you use?"

"My doctor gave me a cream and some pills. I wrote it down—griseofulvin. I took it for a month, but it didn't help."

"Tinea affects the scalp mostly in kids," I tell Darlene, "and Ricardo is 23. Also, tinea causes hair loss, which he doesn't have."

"If it's inflammatory, treat it as a fungus," she says with a sly smile, "and if it's a fungus …"

"You said it," I tell her, "but I thought it."

The Internet Post

Thursday was unusual, but such stories are not. Here's a typical Internet post:

I saw a doctor a couple times because a small lesion appeared near my urethra last September. It's small and doesn't bother me much, but it weeps a clear fluid. It also came along with dry skin/redness on my scrotum, which bothers me occasionally. The doctor told me it was nothing to worry about and it was just a fungus.

What fungus would that be, exactly?

Differentiating an inflammatory dermatosis from a fungus or yeast can be tricky: Scrapings are sometimes unreliable, cultures delayed and overgrown with contaminants.

I confess to my share of "whoops" moments when the sight of spreading, polycyclic lesions on the ankles or neck showed that a topical steroid might not have been such a good idea after all. When it comes to papulosquamous rashes, there are just two basic choices—fungus or not fungus—and two outcomes—better and not better. This isn't rocket science.

Yet, year in and year out, people troop in to show me nummular eczema that their doctors, some even older than I am, have been treating with endless applications of Lamisil (terbinafine) or clotrimazole. The monotony of such cases is relieved only by the occasional unfortunate with Candida or tinea who's never been taken off the triamcinolone or steroid-antifungal combination that's clearly making things worse.

There's a big push these days to rate (and pay) physicians based on their efficient use of evidence-based therapies with reliable outcomes. Here, I suggest, is a good place to start: Train doctors while they're still in school that, wet or dry, if it's a fungus, treat it as one, and if it isn't, don't.

Nondermatologists like to mock, "Hey, we know what you guys do: If it's wet, dry it, and if it's dry, wet it."

Most of the students who follow me around are headed for primary care. When I meet a new one, I'm tempted to say, "The goal of this elective is to make sure that, by the time you leave, you won't say, 'If it's eczema, I'll treat it as a fungus, and if it's a fungus, I'll treat it with a steroid.'"

That would be snide and condescending, though, so I stifle the impulse. But then comes a new student, Darlene, and a day like last Thursday. …

Case 1

"Doc, I have this rash between my butt cheeks, and the cream I'm using doesn't help at all."

"Which cream is that?"

"Clotrimazole."

"See the pinkness spanning the cleft?" I show Darlene. "That's inverse psoriasis, so clotrimazole won't work. He needs a steroid."

Case 2

"It's been a week, Fred. How are you?"

"My butt feels much better, Doc. The itch was maddening."

His gluteal cleft looks all clear. A couple of weeks of nystatin-triamcinolone had left him with a nice rim of satellite pustules and a lot of itch. Econazole did the trick.

"He had a yeast infection," I say. "The triamcinolone trumped the nystatin. A straight antiyeast cream is what he needed."

"Isn't that the opposite of the other patient?" Darlene asks.

The kids are so smart these days.

Case 3

"How long has Vince had this scaling on his soles?"

"He's 10, so I guess it's about 6 years."

"And what has his pediatrician recommended?"

"An antifungal cream. It sort of works. After 2 weeks of using it, the scaling is a little better."

"Let's try a different approach. Foot rashes on prepubertal kids are usually eczematous rather than fungal," I explain.

"Why didn't the pediatrician change the prescription?" Darlene asks.

"Probably because the patient didn't complain. The fungus cream is a cream, after all, so it smoothed things down a bit."

"But for 6 years?"

Case 4

Ricardo has a patch of psoriasis peeking out from his right frontal scalp. Nice pink, micaceous scale. Clearly defined outline. Treatment hasn't been working.

"What did you use?"

"My doctor gave me a cream and some pills. I wrote it down—griseofulvin. I took it for a month, but it didn't help."

"Tinea affects the scalp mostly in kids," I tell Darlene, "and Ricardo is 23. Also, tinea causes hair loss, which he doesn't have."

"If it's inflammatory, treat it as a fungus," she says with a sly smile, "and if it's a fungus …"

"You said it," I tell her, "but I thought it."

The Internet Post

Thursday was unusual, but such stories are not. Here's a typical Internet post:

I saw a doctor a couple times because a small lesion appeared near my urethra last September. It's small and doesn't bother me much, but it weeps a clear fluid. It also came along with dry skin/redness on my scrotum, which bothers me occasionally. The doctor told me it was nothing to worry about and it was just a fungus.

What fungus would that be, exactly?

Differentiating an inflammatory dermatosis from a fungus or yeast can be tricky: Scrapings are sometimes unreliable, cultures delayed and overgrown with contaminants.

I confess to my share of "whoops" moments when the sight of spreading, polycyclic lesions on the ankles or neck showed that a topical steroid might not have been such a good idea after all. When it comes to papulosquamous rashes, there are just two basic choices—fungus or not fungus—and two outcomes—better and not better. This isn't rocket science.

Yet, year in and year out, people troop in to show me nummular eczema that their doctors, some even older than I am, have been treating with endless applications of Lamisil (terbinafine) or clotrimazole. The monotony of such cases is relieved only by the occasional unfortunate with Candida or tinea who's never been taken off the triamcinolone or steroid-antifungal combination that's clearly making things worse.

There's a big push these days to rate (and pay) physicians based on their efficient use of evidence-based therapies with reliable outcomes. Here, I suggest, is a good place to start: Train doctors while they're still in school that, wet or dry, if it's a fungus, treat it as one, and if it isn't, don't.

The first boss I had after leaving my pediatric residency had trained at the Harriet Lane service at Johns Hopkins. One day he started reminiscing about how things had changed since his day. I had taken night call once every third night in my residency, and the residents at our UConn-affiliated program were currently on every fourth.

"At Hopkins they made a concession while I was there—they allowed us to get married. We were on every other night, but we couldn't leave the compound even on the off nights. That's why they called us interns—in case one of our own patients got sick."

"Sure," I remember thinking at the time, "the Days of the Giants." I resented his clear subtext: "You whippersnappers don't work like we did."

I was young, though, and not yet acquainted with the wisdom of great philosophers like Mel Brooks' 2000-year-old man ("We mock the thing we are to be") and Pogo ("We have met the enemy and he is us").

The Romans used to say that times change, and we change with them. What triggered my thinking of changing times has been the doings not just of young folks but of colleagues my age or older.

My medical neighborhood has been infected with "conciergitis": All at once, several established internists joined the boutique bandwagon, slashed their panels from a few thousand patients to a few hundred, and asked those who signed on to pay annual fees of $1,500-$4,000 over and above what insurance pays.

And what do the patients get for these fees? The promise of being able to reach their doctors promptly, be seen fast, and have phone calls returned.

Funny, I thought that's what doctors were supposed to do anyway. How old-fashioned of me.

Doctors are "boutiquing" both because they feel they need to and because they can. My own internist of 25 years, Doug, ferociously opposed concierge medicine when it first appeared around here a few years ago, yet he has recently signed on with a national boutique firm.

"My only other choice was to retire," he told me. "My junior associate Karen is only 34, but she's burned out after only 4 years. She's taken a job as a hospitalist so she can have a personal life. My partner quit primary care and took a job doing just GI. With all the paperwork and staffing costs, the practice wasn't financially viable if I ran it myself."

Times change in many ways. Besides new circumstances like the burdens of paperwork and government regulations, there are also shifting attitudes and expectations.

Slowly, imperceptibly, people decide they're no longer willing to do what used to be taken for granted. They want personal lives. They find out that Peter, Paul, and Meg aren't putting up with things everyone used to accept, so the scales fall from their eyes and they don't see why they should either.

Times change whether we want them to or not, but changing with them gets harder as we age and our adaptive arteries harden.

Starting out, I built my practice on HMO referrals because many older colleagues decided that HMOs were just a fad and they weren't going along with the referral thing. Eventually, most came around because they had to. Those who didn't gave up and quit.

No need to enumerate all the changes since then: E/M codes, OSHA, CLIA, EMRs, etc. And the pace of change isn't slowing down.

As times change, one thing seems to stay the same: Older folks think that youngsters don't know what real work means, and the younger generation does not want to hear it.

When I took over the remains of a practice in 1981, the retiring gentleman showed me around his office, a converted garage, and said, "You newcomers can't get along without things we never needed. You insist on secretaries." I was too polite to respond, but I remember what I thought.

Like the man said, "We mock the thing we are to be."

Now, at the other end of my career, I face the prospect of hiring younger associates who will expect to earn guaranteed top dollar the first year out of training and, of course, to work no more than 4 days a week.

I could tell them my personal saga—the first office in the back room of a brownstone, the many part-time jobs while waiting for the phone to ring, and so forth—but nobody wants to hear that. Times change. This is now.

Either you have the flexibility to change with the times or you decide it's not worth the effort anymore. I'm trying to be flexible. Doug may have concierged off into the sunset, but I found another doctor who calls me back, even without a membership fee. He only has office hours on 4 days, but, hey, nobody's perfect.

The first boss I had after leaving my pediatric residency had trained at the Harriet Lane service at Johns Hopkins. One day he started reminiscing about how things had changed since his day. I had taken night call once every third night in my residency, and the residents at our UConn-affiliated program were currently on every fourth.

"At Hopkins they made a concession while I was there—they allowed us to get married. We were on every other night, but we couldn't leave the compound even on the off nights. That's why they called us interns—in case one of our own patients got sick."

"Sure," I remember thinking at the time, "the Days of the Giants." I resented his clear subtext: "You whippersnappers don't work like we did."

I was young, though, and not yet acquainted with the wisdom of great philosophers like Mel Brooks' 2000-year-old man ("We mock the thing we are to be") and Pogo ("We have met the enemy and he is us").

The Romans used to say that times change, and we change with them. What triggered my thinking of changing times has been the doings not just of young folks but of colleagues my age or older.

My medical neighborhood has been infected with "conciergitis": All at once, several established internists joined the boutique bandwagon, slashed their panels from a few thousand patients to a few hundred, and asked those who signed on to pay annual fees of $1,500-$4,000 over and above what insurance pays.

And what do the patients get for these fees? The promise of being able to reach their doctors promptly, be seen fast, and have phone calls returned.

Funny, I thought that's what doctors were supposed to do anyway. How old-fashioned of me.

Doctors are "boutiquing" both because they feel they need to and because they can. My own internist of 25 years, Doug, ferociously opposed concierge medicine when it first appeared around here a few years ago, yet he has recently signed on with a national boutique firm.

"My only other choice was to retire," he told me. "My junior associate Karen is only 34, but she's burned out after only 4 years. She's taken a job as a hospitalist so she can have a personal life. My partner quit primary care and took a job doing just GI. With all the paperwork and staffing costs, the practice wasn't financially viable if I ran it myself."

Times change in many ways. Besides new circumstances like the burdens of paperwork and government regulations, there are also shifting attitudes and expectations.

Slowly, imperceptibly, people decide they're no longer willing to do what used to be taken for granted. They want personal lives. They find out that Peter, Paul, and Meg aren't putting up with things everyone used to accept, so the scales fall from their eyes and they don't see why they should either.

Times change whether we want them to or not, but changing with them gets harder as we age and our adaptive arteries harden.

Starting out, I built my practice on HMO referrals because many older colleagues decided that HMOs were just a fad and they weren't going along with the referral thing. Eventually, most came around because they had to. Those who didn't gave up and quit.

No need to enumerate all the changes since then: E/M codes, OSHA, CLIA, EMRs, etc. And the pace of change isn't slowing down.

As times change, one thing seems to stay the same: Older folks think that youngsters don't know what real work means, and the younger generation does not want to hear it.

When I took over the remains of a practice in 1981, the retiring gentleman showed me around his office, a converted garage, and said, "You newcomers can't get along without things we never needed. You insist on secretaries." I was too polite to respond, but I remember what I thought.

Like the man said, "We mock the thing we are to be."

Now, at the other end of my career, I face the prospect of hiring younger associates who will expect to earn guaranteed top dollar the first year out of training and, of course, to work no more than 4 days a week.

I could tell them my personal saga—the first office in the back room of a brownstone, the many part-time jobs while waiting for the phone to ring, and so forth—but nobody wants to hear that. Times change. This is now.

Either you have the flexibility to change with the times or you decide it's not worth the effort anymore. I'm trying to be flexible. Doug may have concierged off into the sunset, but I found another doctor who calls me back, even without a membership fee. He only has office hours on 4 days, but, hey, nobody's perfect.

The first boss I had after leaving my pediatric residency had trained at the Harriet Lane service at Johns Hopkins. One day he started reminiscing about how things had changed since his day. I had taken night call once every third night in my residency, and the residents at our UConn-affiliated program were currently on every fourth.

"At Hopkins they made a concession while I was there—they allowed us to get married. We were on every other night, but we couldn't leave the compound even on the off nights. That's why they called us interns—in case one of our own patients got sick."

"Sure," I remember thinking at the time, "the Days of the Giants." I resented his clear subtext: "You whippersnappers don't work like we did."

I was young, though, and not yet acquainted with the wisdom of great philosophers like Mel Brooks' 2000-year-old man ("We mock the thing we are to be") and Pogo ("We have met the enemy and he is us").

The Romans used to say that times change, and we change with them. What triggered my thinking of changing times has been the doings not just of young folks but of colleagues my age or older.

My medical neighborhood has been infected with "conciergitis": All at once, several established internists joined the boutique bandwagon, slashed their panels from a few thousand patients to a few hundred, and asked those who signed on to pay annual fees of $1,500-$4,000 over and above what insurance pays.

And what do the patients get for these fees? The promise of being able to reach their doctors promptly, be seen fast, and have phone calls returned.

Funny, I thought that's what doctors were supposed to do anyway. How old-fashioned of me.

Doctors are "boutiquing" both because they feel they need to and because they can. My own internist of 25 years, Doug, ferociously opposed concierge medicine when it first appeared around here a few years ago, yet he has recently signed on with a national boutique firm.

"My only other choice was to retire," he told me. "My junior associate Karen is only 34, but she's burned out after only 4 years. She's taken a job as a hospitalist so she can have a personal life. My partner quit primary care and took a job doing just GI. With all the paperwork and staffing costs, the practice wasn't financially viable if I ran it myself."

Times change in many ways. Besides new circumstances like the burdens of paperwork and government regulations, there are also shifting attitudes and expectations.

Slowly, imperceptibly, people decide they're no longer willing to do what used to be taken for granted. They want personal lives. They find out that Peter, Paul, and Meg aren't putting up with things everyone used to accept, so the scales fall from their eyes and they don't see why they should either.

Times change whether we want them to or not, but changing with them gets harder as we age and our adaptive arteries harden.

Starting out, I built my practice on HMO referrals because many older colleagues decided that HMOs were just a fad and they weren't going along with the referral thing. Eventually, most came around because they had to. Those who didn't gave up and quit.

No need to enumerate all the changes since then: E/M codes, OSHA, CLIA, EMRs, etc. And the pace of change isn't slowing down.

As times change, one thing seems to stay the same: Older folks think that youngsters don't know what real work means, and the younger generation does not want to hear it.

When I took over the remains of a practice in 1981, the retiring gentleman showed me around his office, a converted garage, and said, "You newcomers can't get along without things we never needed. You insist on secretaries." I was too polite to respond, but I remember what I thought.

Like the man said, "We mock the thing we are to be."

Now, at the other end of my career, I face the prospect of hiring younger associates who will expect to earn guaranteed top dollar the first year out of training and, of course, to work no more than 4 days a week.

I could tell them my personal saga—the first office in the back room of a brownstone, the many part-time jobs while waiting for the phone to ring, and so forth—but nobody wants to hear that. Times change. This is now.

Either you have the flexibility to change with the times or you decide it's not worth the effort anymore. I'm trying to be flexible. Doug may have concierged off into the sunset, but I found another doctor who calls me back, even without a membership fee. He only has office hours on 4 days, but, hey, nobody's perfect.

Chad sat on the exam table with an elegant black bag from Amphora, a local purveyor of high-end skin care products.

"I need a prescription for Protopic," he said.

"I'll put in for Prior Authorization," I replied. "But your insurance may not cover it."

So he asked for samples. Then he asked for a prescription for Propecia. Then he asked about Botox and Restylane.

People's attitudes toward spending money can be hard to figure. Take Eunice, for example, who came by later the same day for me to remove a lesion on her shin that biopsy had shown to be a basal cell carcinoma. She showed me another spot on her arm.

"Could be the same thing," I said.

"The last biopsy cost me $127 after insurance," she said. "Must you biopsy this one, too?"

I told her that I must.

While I curetted her leg and arm, Eunice reported on her recent trip. "The cruise was fabulous," she said. "We've tried different lines, but Royal Flushing is the best. There are thousands of passengers, but you always feel like you're getting personal service."

"Where did you go?" I asked.

"Athens, the Greek islands, Rome, Venice. You know what the best part was—Lido. It's a small island near Venice, away from the tourists, very quiet, really lovely."

And not covered by health insurance, presumably.

So it's okay to spend money on Propecia, Botox, and Lido, but not on Protopic or a biopsy.

But the paradox is only apparent, not real. In fact, people divide the world in two: things you're supposed to pay for and things somebody else is supposed to pay for. What matters is not the size of the expenditure, but the category. How things get classified is a matter for economic anthropologists to figure out. But get classified they do.

I mention Chad and Eunice not just because they're fresh in my mind but because they're middle class. The kind of paradoxical economic behavior I'm describing is more often blamed on "welfare queens." Money for frivolities while stinting the essentials.

Not that I exempt myself from such attitudes. I confess to irritation when Mrs. Will Medicaid Cover This? tells me about her recent jaunt to somewhere tropical. The phenomenon, however, is not limited to the poor, or to the bourgeoisie, petty or haute, which brings me to the wealthy.

Gilbert drops by twice a year. He tells me about his efforts to raise funds for his alma mater, a venerable and well-endowed southern institute of higher learning of which he is very proud.

"We set a goal of $1.3 billion for our capital campaign," he told me recently. "But we're already over a billion, so we've raised the goal to $1.7 billion."

I would have whistled if I knew how.

Gilbert went on to tell me about recruitment. "You might think we wouldn't do this with competitors," he said, "But we recruit with a consortium of other universities from our neck of the woods. It's more economical that way.

"Someone messed up when the recruiters went out to Denver last year and didn't book the hall we use every year. So they called one of the local private prep schools and asked about using an auditorium. They said sure, but it was going to cost $1,800. Can you imagine?

"So we said, hey, there's this consortium of well-known southern schools coming to your place. Our being there will do a lot for your prestige.

"They agreed that it would, and they'd be delighted to have us, but for $1,800."

"What did you do?" I asked him.

Gilbert smiled. "I have some contacts out there." He said. "One of them is a charter member of the Presbyopia Hunt Club. We used their facility, which worked out fine. It cost us $750."

Money for endowments? Check. Money for buildings and grounds? Check. Money for salaries? Nah, I know too many professors and postdoctorates to think that's the case.

Now if I were going on grandly about 10-figure sums, I would be, well, embarrassed to brag about how I saved a grand off somebody's standard fee which they didn't have the sense to discount for the honor of serving me. But that's just me.

The point is that no single class has a monopoly on inscrutable economic behavior. One should therefore be understanding and sympathetic to all. But the flesh is weak, and some people are, for me at least, a little harder to sympathize with.

Chad sat on the exam table with an elegant black bag from Amphora, a local purveyor of high-end skin care products.

"I need a prescription for Protopic," he said.

"I'll put in for Prior Authorization," I replied. "But your insurance may not cover it."

So he asked for samples. Then he asked for a prescription for Propecia. Then he asked about Botox and Restylane.

People's attitudes toward spending money can be hard to figure. Take Eunice, for example, who came by later the same day for me to remove a lesion on her shin that biopsy had shown to be a basal cell carcinoma. She showed me another spot on her arm.

"Could be the same thing," I said.

"The last biopsy cost me $127 after insurance," she said. "Must you biopsy this one, too?"

I told her that I must.

While I curetted her leg and arm, Eunice reported on her recent trip. "The cruise was fabulous," she said. "We've tried different lines, but Royal Flushing is the best. There are thousands of passengers, but you always feel like you're getting personal service."

"Where did you go?" I asked.

"Athens, the Greek islands, Rome, Venice. You know what the best part was—Lido. It's a small island near Venice, away from the tourists, very quiet, really lovely."

And not covered by health insurance, presumably.

So it's okay to spend money on Propecia, Botox, and Lido, but not on Protopic or a biopsy.

But the paradox is only apparent, not real. In fact, people divide the world in two: things you're supposed to pay for and things somebody else is supposed to pay for. What matters is not the size of the expenditure, but the category. How things get classified is a matter for economic anthropologists to figure out. But get classified they do.

I mention Chad and Eunice not just because they're fresh in my mind but because they're middle class. The kind of paradoxical economic behavior I'm describing is more often blamed on "welfare queens." Money for frivolities while stinting the essentials.

Not that I exempt myself from such attitudes. I confess to irritation when Mrs. Will Medicaid Cover This? tells me about her recent jaunt to somewhere tropical. The phenomenon, however, is not limited to the poor, or to the bourgeoisie, petty or haute, which brings me to the wealthy.

Gilbert drops by twice a year. He tells me about his efforts to raise funds for his alma mater, a venerable and well-endowed southern institute of higher learning of which he is very proud.

"We set a goal of $1.3 billion for our capital campaign," he told me recently. "But we're already over a billion, so we've raised the goal to $1.7 billion."

I would have whistled if I knew how.

Gilbert went on to tell me about recruitment. "You might think we wouldn't do this with competitors," he said, "But we recruit with a consortium of other universities from our neck of the woods. It's more economical that way.

"Someone messed up when the recruiters went out to Denver last year and didn't book the hall we use every year. So they called one of the local private prep schools and asked about using an auditorium. They said sure, but it was going to cost $1,800. Can you imagine?

"So we said, hey, there's this consortium of well-known southern schools coming to your place. Our being there will do a lot for your prestige.

"They agreed that it would, and they'd be delighted to have us, but for $1,800."

"What did you do?" I asked him.

Gilbert smiled. "I have some contacts out there." He said. "One of them is a charter member of the Presbyopia Hunt Club. We used their facility, which worked out fine. It cost us $750."

Money for endowments? Check. Money for buildings and grounds? Check. Money for salaries? Nah, I know too many professors and postdoctorates to think that's the case.

Now if I were going on grandly about 10-figure sums, I would be, well, embarrassed to brag about how I saved a grand off somebody's standard fee which they didn't have the sense to discount for the honor of serving me. But that's just me.

The point is that no single class has a monopoly on inscrutable economic behavior. One should therefore be understanding and sympathetic to all. But the flesh is weak, and some people are, for me at least, a little harder to sympathize with.

Chad sat on the exam table with an elegant black bag from Amphora, a local purveyor of high-end skin care products.

"I need a prescription for Protopic," he said.

"I'll put in for Prior Authorization," I replied. "But your insurance may not cover it."

So he asked for samples. Then he asked for a prescription for Propecia. Then he asked about Botox and Restylane.

People's attitudes toward spending money can be hard to figure. Take Eunice, for example, who came by later the same day for me to remove a lesion on her shin that biopsy had shown to be a basal cell carcinoma. She showed me another spot on her arm.

"Could be the same thing," I said.

"The last biopsy cost me $127 after insurance," she said. "Must you biopsy this one, too?"

I told her that I must.

While I curetted her leg and arm, Eunice reported on her recent trip. "The cruise was fabulous," she said. "We've tried different lines, but Royal Flushing is the best. There are thousands of passengers, but you always feel like you're getting personal service."

"Where did you go?" I asked.

"Athens, the Greek islands, Rome, Venice. You know what the best part was—Lido. It's a small island near Venice, away from the tourists, very quiet, really lovely."

And not covered by health insurance, presumably.

So it's okay to spend money on Propecia, Botox, and Lido, but not on Protopic or a biopsy.

But the paradox is only apparent, not real. In fact, people divide the world in two: things you're supposed to pay for and things somebody else is supposed to pay for. What matters is not the size of the expenditure, but the category. How things get classified is a matter for economic anthropologists to figure out. But get classified they do.

I mention Chad and Eunice not just because they're fresh in my mind but because they're middle class. The kind of paradoxical economic behavior I'm describing is more often blamed on "welfare queens." Money for frivolities while stinting the essentials.

Not that I exempt myself from such attitudes. I confess to irritation when Mrs. Will Medicaid Cover This? tells me about her recent jaunt to somewhere tropical. The phenomenon, however, is not limited to the poor, or to the bourgeoisie, petty or haute, which brings me to the wealthy.

Gilbert drops by twice a year. He tells me about his efforts to raise funds for his alma mater, a venerable and well-endowed southern institute of higher learning of which he is very proud.

"We set a goal of $1.3 billion for our capital campaign," he told me recently. "But we're already over a billion, so we've raised the goal to $1.7 billion."

I would have whistled if I knew how.

Gilbert went on to tell me about recruitment. "You might think we wouldn't do this with competitors," he said, "But we recruit with a consortium of other universities from our neck of the woods. It's more economical that way.

"Someone messed up when the recruiters went out to Denver last year and didn't book the hall we use every year. So they called one of the local private prep schools and asked about using an auditorium. They said sure, but it was going to cost $1,800. Can you imagine?

"So we said, hey, there's this consortium of well-known southern schools coming to your place. Our being there will do a lot for your prestige.

"They agreed that it would, and they'd be delighted to have us, but for $1,800."

"What did you do?" I asked him.

Gilbert smiled. "I have some contacts out there." He said. "One of them is a charter member of the Presbyopia Hunt Club. We used their facility, which worked out fine. It cost us $750."

Money for endowments? Check. Money for buildings and grounds? Check. Money for salaries? Nah, I know too many professors and postdoctorates to think that's the case.

Now if I were going on grandly about 10-figure sums, I would be, well, embarrassed to brag about how I saved a grand off somebody's standard fee which they didn't have the sense to discount for the honor of serving me. But that's just me.

The point is that no single class has a monopoly on inscrutable economic behavior. One should therefore be understanding and sympathetic to all. But the flesh is weak, and some people are, for me at least, a little harder to sympathize with.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

One day in late August I was explaining to Maria how to apply hydroquinone to the extra pigmentation on her upper lip.

"It will work better after Labor Day," I said, "when the sun isn't so strong. Please apply it morning and night, and be sure to use sunscreen whenever you go outdoors. I'll see you back in 2 months."

"I may be in the sun then," she said. "I probably will be taking my son to Disney. He has leukemia, and the doctors say that they can't do anything more for him."

I was speechless. Here I was, discoursing on melasma to a woman planning Christmas in October for a little son on the brink of death.

"Edgar got sick when he was 10 months old," Maria said. "The medicines helped for a while. Now he's 7. But they don't work anymore. So we're taking him to Disney."

Like everyone, all our patients have stories. Some have several: banal, amusing, frustrating, tragic. At times we can infer them from their skin complaints or from conversational byplay. Mostly, however, we treat the superficialities, with barely any idea of what goes on underneath. It could hardly be otherwise; what's down there is not our business. And how much can you learn in a few minutes assigned to the skin?

Then someone like Maria comes along, to remind us of how limited our role actually is, how little we understand the people we take care of, how trifling, in the larger scheme of things, are the therapies we have at our disposal.

Earlier this year I had two such reminders on the same day. Laurel brought in Emma, her chunky 5-year-old. That Emma had atopic dermatitis was evident from her antecubital spaces even before she reached the exam table. Laurel shuffled in, looking unkempt and disheveled. She had dirty, two-inch nails. Her skin was sallow, her voice grating—a smoker who didn't take care of herself, no doubt. "Emma, get up on the table and sit still!" she rasped.

"Emma has eczema," I told her. "I'll give you some cream for it."

"Thanks, Doc," she said. "I'm trying to get things straightened out for her as much as I can. I have Lou Gehrig's disease, or at least that's what the doctors think. That's why I talk like this.

"I don't know how much longer I'm going to be able to take care of her. But there isn't anybody else. I have no family. There's just me." She forced herself clumsily to her feet. "It's a hard life," she said, lurching over to help Emma down. I handed her the prescription for a topical steroid. That is all I had to offer.

A few hours later a waif came in, accompanied by an attendant from an agency. The chart said Ellen was 12, though she looked no more than 8. Even a cursory glance made it plain that Ellen was gouging herself. Fresh wounds marred her arms, alongside healed scars. Common enough in adults, but not so much in a child.

"I scratch myself sometimes," she said. "My psychiatrist is helping me with that."

"Does your skin itch?" I asked.

"Sometimes," she said. "But sometimes I just get nervous. It depends on my foster parents. When I'm with a new family it takes me a while to feel at home. I worry that maybe they won't like me, and I'll have to move again.

"But now I'm in a good home!" She now spoke with urgency. "So I'm hoping I can stay with them for a while. And when I feel good, I don't pick at my skin so much."

Once again, I prescribed something, which is what I was expected to do. An application as an alternative to self-mutilation. Her psychiatrist could work on her self-esteem, even as her circumstances dismantled what was left of it.

Cases like these are, of course, exceptional. Ours is mostly a cheerful specialty. Such stress as we get wind of—a lost job, parent-teen tensions—are mild and conventional, or at least they seem that way to us. As outsiders, we have a conveniently limited role. We offer our superficial ministrations, skating blithely along the surface.

Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.

"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.

There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.

This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.

We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")

Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.

For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.

Even light-related changes that have nothing to do with cancer—photosensitivity from doxycycline, for instance—cause concern, because "they came right after sun exposure."

Patients who have moles that look funny to them (like halo nevi)—or which someone has told them to "keep an eye on—may take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boom—moles cancerize.

Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.

The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:

"What are these crusty spots, Doctor?"

"Solar keratoses, Mrs. Goldfarb. They're from the sun."

"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")

Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.

Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.

Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.

No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.

Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.

"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.

There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.

This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.

We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")

Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.

For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.

Even light-related changes that have nothing to do with cancer—photosensitivity from doxycycline, for instance—cause concern, because "they came right after sun exposure."

Patients who have moles that look funny to them (like halo nevi)—or which someone has told them to "keep an eye on—may take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boom—moles cancerize.

Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.

The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:

"What are these crusty spots, Doctor?"

"Solar keratoses, Mrs. Goldfarb. They're from the sun."

"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")

Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.

Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.

Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.

No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.

Henrietta had certainly seen some sun in her 50-plus years. Her skin looked and felt like beef jerky. Still, it was one specific sunburn that she recalled.

"Ten years ago in Aruba," she said, "I fell asleep on the beach and burned like crazy. The next year I got four basal cell cancers." She showed me the excision scars on her chest and back.

There are many ways in which patients and physicians just don't think alike. One example of special relevance to us in the skin trade is the concept of latency. We use it all the time, without much thought. We figure that patients are exposed to the herpes simplex or human papillomavirus, but it doesn't become visible until who-knows-how-long later. In the same regard, patients get several childhood sunburns, or chronic, continual sun exposure in adult life, and eventually basal or squamous cell carcinomas pop up.

This makes sense to us, but not much to Henrietta. To her, the problem wasn't all those years on beaches; it was the one big burn in Aruba that did it. If that wasn't it, she might say, how come she got her only four basal cells in the year just after, and none since? Call it the Big Bang theory of sun damage.

We realize of course that our model of carcinogenesis fails to explain much that we see clinically. Why, for instance, do some patients get nonmelanoma skin cancers only or mostly on their trunks and not their faces? Why do basal cells often appear in places where the sun never shines? (Favorite anecdote: Making conversation while curetting a basal cell on the buttock of a 75-year-old white-as-snow grandma, I said, "I guess we don't have to worry that you had sun exposure here, Mrs. Green." "But Doctor," she piped, "I'm a nudist!")

Henrietta's way of thinking has consequences that are, from our perspective, unfortunate: It can make patients worry when they needn't and not worry when they should.

For instance, as each summer ends people flock to our offices, tanned and guilt ridden. They're sure that their recent indulgences have provoked any number of spots to burst into cancer. Sometimes people multiply their anxiety by staring at moles they never noticed before, or by picking or rubbing lesions that they think have changed.

Even light-related changes that have nothing to do with cancer—photosensitivity from doxycycline, for instance—cause concern, because "they came right after sun exposure."

Patients who have moles that look funny to them (like halo nevi)—or which someone has told them to "keep an eye on—may take excessive and burdensome precautions such as putting Band-Aids on the moles every time they go out. (Ask your patients; you'd be surprised how many do this.) Again, their assumption is that one bad burn, and boom—moles cancerize.

Once diagnosed with sun-related malignancies, or even premalignant keratoses, older people often conclude that they shouldn't go outdoors at all, ever.

The flip side of not being able to wrap their brains around concepts like cumulative damage or latency shows itself in situations like this familiar one:

"What are these crusty spots, Doctor?"

"Solar keratoses, Mrs. Goldfarb. They're from the sun."

"But I haven't gone out in the sun in 20 years!" (Delicacy prevents responding, "True, but you're 80 now.")

Younger patients who like to swim or sail and have many years of potential sun exposure ahead of them may find themselves unable to adopt a regular routine of sun protection. They think all they have to do is prevent one bad sunburn, the kind that Henrietta is certain did her in.

Counseling people in these matters should take into account not just facts but the way patients process them. Concepts such as initiating or triggering carcinogenesis just don't compute for many of our patients, who filter them through their own ways of understanding. What comes through often remains the unshakable belief that what really matters is not what's happened over the long term but what they did yesterday or what they'll do tomorrow. The same might well be said of other behaviors, such as exercise, weight loss, or healthy diet.

Changing the way people act in matters like this means not just lecturing or conveying information but rewiring brains. Doing that takes a will and sustained commitment which, frankly, most of us practicing physicians are unable to make. In their absence, the least we can do is pay attention to the way our words are actually heard.

No doubt Henrietta will be even browner and crinklier next year. But I'll do my best to make sure she comes back for a checkup anyway.

Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."

You would think she was in grade school and had just gotten her report card. In a way, you'd be right.

Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.

How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.

If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.

But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.

Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.

Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.

This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.

▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.

▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.

▸ There is another basal cell, but you have fewer actinic keratoses than last time.

And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.

Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"

This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.

My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.

Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."

You would think she was in grade school and had just gotten her report card. In a way, you'd be right.

Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.

How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.

If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.

But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.

Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.

Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.

This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.

▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.

▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.

▸ There is another basal cell, but you have fewer actinic keratoses than last time.

And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.

Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"

This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.

My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.

Aunt Bessie was beaming. She stopped by my office after her physical with her doctor on the third floor. "I got a good report!" she exclaimed. "Dr. Wax was delighted with my x-ray, and she just couldn't get over how the swelling in my ankles has gone down."

You would think she was in grade school and had just gotten her report card. In a way, you'd be right.

Many years ago I read a book that attacked chiropractors as shameless, self-promoting hucksters. One piece of evidence the author cited was a pamphlet offering advice for new chiropractic practitioners eager to build up their practices. Sample tip: Develop a repertoire of positive things to say. "You're doing very well, today, Mrs. Jones," "Coming along nicely, Mr. Smith," and so on.

How tacky, I thought. Isn't telling the patient she's getting better just an indirect way of saying how terrific you are? Well, maybe, but not necessarily. And even so, it might be worthwhile doing anyway.

If patients were objective, they would view the course of their disease with clinical detachment. In that case they might assess the ups and downs of their symptoms the way they gauge the state of their neighbor's lawn. Green or weedy, facts are facts.

But patients are not objective. They view the course of their disease the way they look at the state of their lawn. Deterioration means more than distressing or threat; it's a personal shortcoming—an embarrassing failing that reflects badly on them. It means they're coming up short, letting the side down, letting us down. Doing well means the opposite.

Back in school if the teacher said, "Excellent answer, Sidney!" you glowed. If she frowned and shook her head, you felt rotten. You reacted this way even though hearing the teacher's opinion didn't make you one bit smarter or dumber. Patients react the same way even though the way we assess their progress doesn't make them any healthier or sicker. Like the schoolteacher, we're the authority in charge.

Next time it's relevant, go a little overboard and instead of being cool and objective, praise a patient for doing well, as if he'd achieved something special. Instead of giving you a funny look, he's likely to smile. He'll feel he's done a nice job by getting better. If you tell him he's doing poorly, he'll react accordingly.

This does not suggest making things up or not taking the appropriate steps to make patients do better than they have been. Even when things are not going as well as can be expected, there is always something positive to say.

▸ Your acne hasn't improved that much overall, but you don't have as many cysts as there were.

▸ Your psoriasis has a way to go but the plaques aren't as thick and hyperkeratotic as they used to be.

▸ There is another basal cell, but you have fewer actinic keratoses than last time.

And so on. Whether or not this approach helps drum up business, it gives patients a hopeful outlook and makes them more likely to comply with the treatment plan. Beyond that, however, it just makes them feel better about themselves, their illness, and their general condition. And in a basic sense, patients visit us not just to reduce symptom scores but to feel better.

Aunt Bessie's doctor obviously gets this. She sent a copy of Bessie's lab reports a few days later, extensively annotated in red pen to make clear which "abnormal" values (such as the MCHC) were actually fine. In addition, the doctor had written this cheery assessment: "Great labs, Bessie!"

This cheerleading tone may be a bit too bubbly for everyone's taste, but the impulse behind it is sound. Aunt Bessie beamed again.

My own internist clearly thinks the same way. Years ago he sent me my own labs, circled my cholesterol level, and wrote, "A plus!" Nowadays my cholesterol wouldn't get more than a B minus. And that's with 20 mg of a statin.

A recent news headline read: "Study Says Chatty Doctors Forget Patients."

"How are we today, Mr. Troldhaugen?"

"Well, doctor, I have this itch. You know, down below."

"Oh, don't I know it! I've been fighting that for years. Itch can drive you crazy. It's embarrassing too. I mean scratching in public is always awkward, but when you're a dermatologist … What have you been doing for it?"

"I have this fungus cream the druggist gave me."

"That figures. Fungus is usually the first thing everybody thinks of. I guess it could be a fungus, but if treating that does not work you have to think of other conditions. I had the same experience last time I tried to treat myself. I have all these samples, so I tried one. It was hard to remember to put it on twice a day—made me more sympathetic when my patients don't always follow instructions exactly the way I give them. Anyhow, after a while it got pretty obvious that I was going to need something different, so I took a different sample and sure enough that did the trick."

"Maybe you can prescribe that for me."

"It's interesting how common these symptoms are. People often come over to me outside the office to ask pretty much the same questions, about itch and rashes and so forth. Of course, I can't exactly examine them there in the street, but I can get a pretty good idea of what they have and what they need. After all, I've had the same symptoms myself."

"So, doctor, what would you recommend?"

"And sometimes I've tried to share my experiences when I've had the same things as my patients do, just to show them that their situation isn't as strange or as frustrating as they might have thought. Take my wart, for instance …"

"But I don't have a wart."

"I had a wart on my left thumb. Now that's interesting right there, because I'm right-handed. People always assume that warts are a virus so they must be contagious, but if they were—and I certainly shake hands with a lot of wart patients every day—why would they spread to my left thumb? But in any case it took me 4 years to get rid of mine, even though I have liquid nitrogen so I can freeze myself anytime I want, and I did too. So I used to tell that to people with resistant warts, so they wouldn't feel quite so frustrated."

"Doctor …"

"And you know what? I found that people really didn't want to know about my problems, whether they were the same kind as they had or not. In fact, patients weren't all that interested in what was going on with me in general. Of course, there are some people who've been seeing me for almost 30 years, who are old friends by now. They know the names of my grandchildren and ask after them, that sort of thing. But most other patients don't really want to know what I've been up to, where I'm going on vacation, or what staffing and administrative hassles I'm dealing with. Which kind of seems right, when you consider that they've come not to find out what's wrong with me, but what's wrong with them. Doesn't that make sense?"

"Yes, but …"

"And then I read in the paper that they did this study in Rochester, with hidden mikes or something, and they found out that doctors were gabbing about their own weight problems and exercise programs, apparently with the thought that this would produce greater rapport. Instead, when the doctors heard tapes of what they said, they realized that maybe not 100% of the time, but most of the time talking about themselves had more to do with the doctors than with the patients. Can you believe that?"

"To tell the truth, I can."

"It's amazing how people can see faults in other people but not notice it in themselves. Isn't that right, Mr. Trondheim?"

"Troldhaugen."

"Right. Well, it's been nice chatting with you. Did I give you the prescription?"

A recent news headline read: "Study Says Chatty Doctors Forget Patients."

"How are we today, Mr. Troldhaugen?"

"Well, doctor, I have this itch. You know, down below."

"Oh, don't I know it! I've been fighting that for years. Itch can drive you crazy. It's embarrassing too. I mean scratching in public is always awkward, but when you're a dermatologist … What have you been doing for it?"

"I have this fungus cream the druggist gave me."

"That figures. Fungus is usually the first thing everybody thinks of. I guess it could be a fungus, but if treating that does not work you have to think of other conditions. I had the same experience last time I tried to treat myself. I have all these samples, so I tried one. It was hard to remember to put it on twice a day—made me more sympathetic when my patients don't always follow instructions exactly the way I give them. Anyhow, after a while it got pretty obvious that I was going to need something different, so I took a different sample and sure enough that did the trick."

"Maybe you can prescribe that for me."

"It's interesting how common these symptoms are. People often come over to me outside the office to ask pretty much the same questions, about itch and rashes and so forth. Of course, I can't exactly examine them there in the street, but I can get a pretty good idea of what they have and what they need. After all, I've had the same symptoms myself."

"So, doctor, what would you recommend?"

"And sometimes I've tried to share my experiences when I've had the same things as my patients do, just to show them that their situation isn't as strange or as frustrating as they might have thought. Take my wart, for instance …"

"But I don't have a wart."

"I had a wart on my left thumb. Now that's interesting right there, because I'm right-handed. People always assume that warts are a virus so they must be contagious, but if they were—and I certainly shake hands with a lot of wart patients every day—why would they spread to my left thumb? But in any case it took me 4 years to get rid of mine, even though I have liquid nitrogen so I can freeze myself anytime I want, and I did too. So I used to tell that to people with resistant warts, so they wouldn't feel quite so frustrated."

"Doctor …"

"And you know what? I found that people really didn't want to know about my problems, whether they were the same kind as they had or not. In fact, patients weren't all that interested in what was going on with me in general. Of course, there are some people who've been seeing me for almost 30 years, who are old friends by now. They know the names of my grandchildren and ask after them, that sort of thing. But most other patients don't really want to know what I've been up to, where I'm going on vacation, or what staffing and administrative hassles I'm dealing with. Which kind of seems right, when you consider that they've come not to find out what's wrong with me, but what's wrong with them. Doesn't that make sense?"

"Yes, but …"

"And then I read in the paper that they did this study in Rochester, with hidden mikes or something, and they found out that doctors were gabbing about their own weight problems and exercise programs, apparently with the thought that this would produce greater rapport. Instead, when the doctors heard tapes of what they said, they realized that maybe not 100% of the time, but most of the time talking about themselves had more to do with the doctors than with the patients. Can you believe that?"

"To tell the truth, I can."

"It's amazing how people can see faults in other people but not notice it in themselves. Isn't that right, Mr. Trondheim?"

"Troldhaugen."

"Right. Well, it's been nice chatting with you. Did I give you the prescription?"

A recent news headline read: "Study Says Chatty Doctors Forget Patients."

"How are we today, Mr. Troldhaugen?"

"Well, doctor, I have this itch. You know, down below."

"Oh, don't I know it! I've been fighting that for years. Itch can drive you crazy. It's embarrassing too. I mean scratching in public is always awkward, but when you're a dermatologist … What have you been doing for it?"

"I have this fungus cream the druggist gave me."

"That figures. Fungus is usually the first thing everybody thinks of. I guess it could be a fungus, but if treating that does not work you have to think of other conditions. I had the same experience last time I tried to treat myself. I have all these samples, so I tried one. It was hard to remember to put it on twice a day—made me more sympathetic when my patients don't always follow instructions exactly the way I give them. Anyhow, after a while it got pretty obvious that I was going to need something different, so I took a different sample and sure enough that did the trick."

"Maybe you can prescribe that for me."

"It's interesting how common these symptoms are. People often come over to me outside the office to ask pretty much the same questions, about itch and rashes and so forth. Of course, I can't exactly examine them there in the street, but I can get a pretty good idea of what they have and what they need. After all, I've had the same symptoms myself."

"So, doctor, what would you recommend?"

"And sometimes I've tried to share my experiences when I've had the same things as my patients do, just to show them that their situation isn't as strange or as frustrating as they might have thought. Take my wart, for instance …"

"But I don't have a wart."

"I had a wart on my left thumb. Now that's interesting right there, because I'm right-handed. People always assume that warts are a virus so they must be contagious, but if they were—and I certainly shake hands with a lot of wart patients every day—why would they spread to my left thumb? But in any case it took me 4 years to get rid of mine, even though I have liquid nitrogen so I can freeze myself anytime I want, and I did too. So I used to tell that to people with resistant warts, so they wouldn't feel quite so frustrated."

"Doctor …"

"And you know what? I found that people really didn't want to know about my problems, whether they were the same kind as they had or not. In fact, patients weren't all that interested in what was going on with me in general. Of course, there are some people who've been seeing me for almost 30 years, who are old friends by now. They know the names of my grandchildren and ask after them, that sort of thing. But most other patients don't really want to know what I've been up to, where I'm going on vacation, or what staffing and administrative hassles I'm dealing with. Which kind of seems right, when you consider that they've come not to find out what's wrong with me, but what's wrong with them. Doesn't that make sense?"

"Yes, but …"

"And then I read in the paper that they did this study in Rochester, with hidden mikes or something, and they found out that doctors were gabbing about their own weight problems and exercise programs, apparently with the thought that this would produce greater rapport. Instead, when the doctors heard tapes of what they said, they realized that maybe not 100% of the time, but most of the time talking about themselves had more to do with the doctors than with the patients. Can you believe that?"

"To tell the truth, I can."

"It's amazing how people can see faults in other people but not notice it in themselves. Isn't that right, Mr. Trondheim?"

"Troldhaugen."

"Right. Well, it's been nice chatting with you. Did I give you the prescription?"

Call me callous, but Sybil really did look like a lizard. Lifelong eczema had turned her face an alarming reddish-purple. Scabs covered her hands. It didn't help that her job as a pharmacist put her in daily contact with dozens of people.

"We haven't seen you in a while," I said. "How often do you use your triamcinolone?"

"I don't use it," she said. "I'm afraid of atrophy."

"You've had a couple of courses of oral antibiotics," I said, "and one of your doctors suggested cyclosporine. Let's try the triamcinolone four times a day for a week, just to see what happens."

Sybil agreed.

A week later Sybil was back, with a big smile on a face now several shades lighter. Her hands were almost healed, too. Medicines work so much better when you use them.

"Do your customers make comments about your eczema when it's out of control?" I asked.

"You bet," said Sybil. "Last week I was giving a man a bottle of hydroxyzine. He looked at my hands and said, 'Take those pills back. I'm not swallowing them if you touched them.'"

Patients with visible disease report that kind of hurtful remark all the time. Although it's easy to be critical of people tactless enough to talk that way, perhaps we should be more understanding of why they do. Though it's just speculation, I have a theory.

Back in 1994, I leased my first pulsed-dye laser, the kind that left deep purple bruises for 10–14 days. Despite counseling showing photos of what to expect, and guaranteeing that the purpura always goes away, patients routinely dissolved into whimpering puddles when they saw what they looked like right after treatment.

One day, Marilyn asked me to treat her facial telangiectases. "I need to stay afterward to apply makeup," she said. "I train monkeys for the blind. If they see me with spots on my face, they'll get upset and start pointing."

That sounded a lot like my patients. I called Marilyn's supervisor to talk this over, but she wasn't interested since I'm not in her field. I asked a friend who teaches biology to put me in touch with his university's primate research center. Such centers don't publish their contact information, fearful of animal rights activists bent on blowing them up.

The Ph.D. student who called me sounded apprehensive. "Who are you?" he whispered.

"Just a dermatologist," I explained. "I was wondering whether this tendency to point agitatedly at red spots might be part of primate behavior that people and monkeys share."

"Are you writing a paper?" he asked. I explained that I was just interested. This threw him a bit, but he promised to send me some references, which turned out to be off point.

I therefore offer only an experienced hunch, but it seems to me that pointing out obvious spots, marks, and other visible but unexpected changes on other humans is a basic impulse. The veneer of civilized tact that helps us suppress this urge often peels right off. Consider how you feel when the person sitting across from you has a piece of food dangling from her lip. Don't you feel overwhelmed with the need to flick it off, or at least point it out? How come?

If you see a shiner on someone's eye, why is it so hard to suppress the compulsion to say, "Look, look, you have a bruise on your eye!" (As though he didn't already know it.) Somehow, redness seems to be a source of special alarm. Ruddy people are routinely greeted with cries of, "You're all red! Are you all right?!" That's perhaps a big reason people find rosacea, which ought to be trivial, so disturbing; pointing with alarm at your own face can't be much fun.

It seems to me that this instinctive impulse is what drives people to point out to others lumps and bumps, dark spots, rashes, and any number of other visible symptoms (coughs, limps, tremors, and so on.) Sometimes this helps get people to seek the help they need. Most other times it's just embarrassing, leaving the pointee feeling stigmatized and ashamed.

People like Sybil will never look entirely normal. We can't stop people from commenting on her appearance, just as we can't prevent pool attendants and fellow swimmers from handing out hurtful guff to patients with widespread psoriasis. Education goes only a short way, whether with humans or our simian cousins.

If we can, it's perhaps better to make her skin change as invisibly as possible so there's nothing to point at.

Sometimes treatment helps people, especially if they use it.

Call me callous, but Sybil really did look like a lizard. Lifelong eczema had turned her face an alarming reddish-purple. Scabs covered her hands. It didn't help that her job as a pharmacist put her in daily contact with dozens of people.

"We haven't seen you in a while," I said. "How often do you use your triamcinolone?"

"I don't use it," she said. "I'm afraid of atrophy."

"You've had a couple of courses of oral antibiotics," I said, "and one of your doctors suggested cyclosporine. Let's try the triamcinolone four times a day for a week, just to see what happens."

Sybil agreed.

A week later Sybil was back, with a big smile on a face now several shades lighter. Her hands were almost healed, too. Medicines work so much better when you use them.

"Do your customers make comments about your eczema when it's out of control?" I asked.

"You bet," said Sybil. "Last week I was giving a man a bottle of hydroxyzine. He looked at my hands and said, 'Take those pills back. I'm not swallowing them if you touched them.'"

Patients with visible disease report that kind of hurtful remark all the time. Although it's easy to be critical of people tactless enough to talk that way, perhaps we should be more understanding of why they do. Though it's just speculation, I have a theory.

Back in 1994, I leased my first pulsed-dye laser, the kind that left deep purple bruises for 10–14 days. Despite counseling showing photos of what to expect, and guaranteeing that the purpura always goes away, patients routinely dissolved into whimpering puddles when they saw what they looked like right after treatment.

One day, Marilyn asked me to treat her facial telangiectases. "I need to stay afterward to apply makeup," she said. "I train monkeys for the blind. If they see me with spots on my face, they'll get upset and start pointing."

That sounded a lot like my patients. I called Marilyn's supervisor to talk this over, but she wasn't interested since I'm not in her field. I asked a friend who teaches biology to put me in touch with his university's primate research center. Such centers don't publish their contact information, fearful of animal rights activists bent on blowing them up.

The Ph.D. student who called me sounded apprehensive. "Who are you?" he whispered.

"Just a dermatologist," I explained. "I was wondering whether this tendency to point agitatedly at red spots might be part of primate behavior that people and monkeys share."

"Are you writing a paper?" he asked. I explained that I was just interested. This threw him a bit, but he promised to send me some references, which turned out to be off point.

I therefore offer only an experienced hunch, but it seems to me that pointing out obvious spots, marks, and other visible but unexpected changes on other humans is a basic impulse. The veneer of civilized tact that helps us suppress this urge often peels right off. Consider how you feel when the person sitting across from you has a piece of food dangling from her lip. Don't you feel overwhelmed with the need to flick it off, or at least point it out? How come?

If you see a shiner on someone's eye, why is it so hard to suppress the compulsion to say, "Look, look, you have a bruise on your eye!" (As though he didn't already know it.) Somehow, redness seems to be a source of special alarm. Ruddy people are routinely greeted with cries of, "You're all red! Are you all right?!" That's perhaps a big reason people find rosacea, which ought to be trivial, so disturbing; pointing with alarm at your own face can't be much fun.

It seems to me that this instinctive impulse is what drives people to point out to others lumps and bumps, dark spots, rashes, and any number of other visible symptoms (coughs, limps, tremors, and so on.) Sometimes this helps get people to seek the help they need. Most other times it's just embarrassing, leaving the pointee feeling stigmatized and ashamed.

People like Sybil will never look entirely normal. We can't stop people from commenting on her appearance, just as we can't prevent pool attendants and fellow swimmers from handing out hurtful guff to patients with widespread psoriasis. Education goes only a short way, whether with humans or our simian cousins.

If we can, it's perhaps better to make her skin change as invisibly as possible so there's nothing to point at.

Sometimes treatment helps people, especially if they use it.

Call me callous, but Sybil really did look like a lizard. Lifelong eczema had turned her face an alarming reddish-purple. Scabs covered her hands. It didn't help that her job as a pharmacist put her in daily contact with dozens of people.

"We haven't seen you in a while," I said. "How often do you use your triamcinolone?"

"I don't use it," she said. "I'm afraid of atrophy."

"You've had a couple of courses of oral antibiotics," I said, "and one of your doctors suggested cyclosporine. Let's try the triamcinolone four times a day for a week, just to see what happens."

Sybil agreed.

A week later Sybil was back, with a big smile on a face now several shades lighter. Her hands were almost healed, too. Medicines work so much better when you use them.

"Do your customers make comments about your eczema when it's out of control?" I asked.

"You bet," said Sybil. "Last week I was giving a man a bottle of hydroxyzine. He looked at my hands and said, 'Take those pills back. I'm not swallowing them if you touched them.'"

Patients with visible disease report that kind of hurtful remark all the time. Although it's easy to be critical of people tactless enough to talk that way, perhaps we should be more understanding of why they do. Though it's just speculation, I have a theory.

Back in 1994, I leased my first pulsed-dye laser, the kind that left deep purple bruises for 10–14 days. Despite counseling showing photos of what to expect, and guaranteeing that the purpura always goes away, patients routinely dissolved into whimpering puddles when they saw what they looked like right after treatment.

One day, Marilyn asked me to treat her facial telangiectases. "I need to stay afterward to apply makeup," she said. "I train monkeys for the blind. If they see me with spots on my face, they'll get upset and start pointing."

That sounded a lot like my patients. I called Marilyn's supervisor to talk this over, but she wasn't interested since I'm not in her field. I asked a friend who teaches biology to put me in touch with his university's primate research center. Such centers don't publish their contact information, fearful of animal rights activists bent on blowing them up.

The Ph.D. student who called me sounded apprehensive. "Who are you?" he whispered.

"Just a dermatologist," I explained. "I was wondering whether this tendency to point agitatedly at red spots might be part of primate behavior that people and monkeys share."

"Are you writing a paper?" he asked. I explained that I was just interested. This threw him a bit, but he promised to send me some references, which turned out to be off point.

I therefore offer only an experienced hunch, but it seems to me that pointing out obvious spots, marks, and other visible but unexpected changes on other humans is a basic impulse. The veneer of civilized tact that helps us suppress this urge often peels right off. Consider how you feel when the person sitting across from you has a piece of food dangling from her lip. Don't you feel overwhelmed with the need to flick it off, or at least point it out? How come?

If you see a shiner on someone's eye, why is it so hard to suppress the compulsion to say, "Look, look, you have a bruise on your eye!" (As though he didn't already know it.) Somehow, redness seems to be a source of special alarm. Ruddy people are routinely greeted with cries of, "You're all red! Are you all right?!" That's perhaps a big reason people find rosacea, which ought to be trivial, so disturbing; pointing with alarm at your own face can't be much fun.

It seems to me that this instinctive impulse is what drives people to point out to others lumps and bumps, dark spots, rashes, and any number of other visible symptoms (coughs, limps, tremors, and so on.) Sometimes this helps get people to seek the help they need. Most other times it's just embarrassing, leaving the pointee feeling stigmatized and ashamed.

People like Sybil will never look entirely normal. We can't stop people from commenting on her appearance, just as we can't prevent pool attendants and fellow swimmers from handing out hurtful guff to patients with widespread psoriasis. Education goes only a short way, whether with humans or our simian cousins.

If we can, it's perhaps better to make her skin change as invisibly as possible so there's nothing to point at.

Sometimes treatment helps people, especially if they use it.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.

Thursday was quite illuminating. Some days are like that. Merle came by in the morning. She places skin care products in health food stores. Merle can do this from anywhere, so last month she did it from Hawaii. "I saw a black spot here that alarmed me," she said, pointing to the crook of her left arm. "It looked like this." Her picture looked like the kind of mask you wear to costume balls, with dark spots for eyes. "I couldn't get an appointment with a dermatologist for weeks," said Merle. "So I applied bloodroot—you know, the black salve."

Of course. The escharotic that's supposed to destroy cancers.

"But then I worried," she said. "How did I know what I was treating?"

How indeed? "Good point," I said.

Merle looked down at her antecubital space, with a patch of proud flesh shaped like her drawing. "I wonder if I drove it inside," she said. "Maybe the cancer is in my bloodstream."

"That's why we like to send moles we remove for biopsy confirmation, rather than just destroy them," I said.

Merle nodded in apparent understanding. "Well, I had to do something," she said. "I couldn't get an appointment with a dermatologist."

Then Brian came in the afternoon, looking haggard. Brian is in commercial real estate. He had scratch marks on his arms and back. "Under much stress?" I asked.

"I'll say," said Brian. "I've been divorced 5 years, and my wife is still coming after me." He then launched into the bitter tale.

"I filed an appeal in superior court," he said. "I brought the document myself and had them stamp it and make me a copy. Then they lost it and refused to hear the appeal. But my luck changed this week," said Brian, brightening a little.

"How's that?" I asked.

"I got a haircut," he said, "and I told my barber what was happening. He told me what to do. He said, 'Take a piece of paper and write your wife's name on it. Then wet the paper, put it in the freezer, and freeze her out of your life!'

"I know it sounds ridiculous," said Brian, "but I did it. I mean, I'd tried everything else. And you know what? Tuesday, one of the court clerks was rummaging on the floor and found my appeal stapled in between two other different papers!"

Merle and Brian may sound a bit extreme, but they illuminate some ways people think and act when it comes to taking care of themselves:

▸ Patients do silly things, despite being quite capable of explaining why these things make no sense even by their own standards.

▸ They tend to act this way when they are fearful or frustrated enough, especially when other people advise it and so reduce any risk of embarrassment. Such advisers need no credentials.

Where health and livelihood are concerned, both Merle and Brian believe in consulting professionals such as doctors, lawyers, and accountants. When it suits them, however, they also take the advice of friends who recommend escharotics and of barbers who suggest sympathetic magic. The contradiction between what they profess and what they do—if they notice it at all—doesn't trouble them.

What makes this odd is that, according to those in and around my own profession, patients are rational actors who engage in health behaviors demonstrated to be in their best interest. Given data and access, they seek out appropriate treatments based on the best current evidence. Properly incentivized, they consult physicians who are objectively superior and more efficient.

All this is true, of course; it ought to be, it must be, and leading experts say it is.

The only problem is that these rational patients live on a planet different from the one I practice on. But I am optimistic that space travel will rapidly improve, so I can visit that planet soon. In the meantime, as they say nowadays, you treat the patients you have.