Under My Skin

Good morning, Mr. Nesia. I see you haven't been here in 15 years."

"I was never here before."

"Forgive me—aren't you Alford M. Nesia, address 36 Endive Gardens Avenue, Boxboro, date of birth April 5, 1954?"

"Yes."

"In that case, you were here in August of 1991."

"I did see a dermatologist once, come to think of it. Was that you?"

It's always nice to know you've made a strong impression. Of course, forgetfulness works both ways:

"Nice to meet you, Ms. Jones."

"I saw you last month, Doctor."

Ouch. This usually happens when my staff checks in an old patient as a new one. Sometimes they haven't been able to find the patient's name in the computer (misspellings, data loss, a 20-year absence, whatever). In other cases, the patient has come in with a child or other relative but never registered under his or her own name. I have a pretty good memory, but without a chart, I'm mostly lost.

Unrecognized patients often make allowances. "You have so many patients, Doctor, you can't possibly remember them all." True enough.

I do try, though. People are often flattered when recognized, offended when they're not. (That's why politicians make such a point of remembering everyone.) Knowing who people are is a good start, but recollecting personal details is even better. I often note such details in the chart, whether they're germane to skin complaints or not. The patient may have started a new job, graduated college, bought a condo, planned a honeymoon in Uzbekistan.

When notes jog my memory about such things, I deftly slip in a personal reference while writing a prescription. "The doxycycline is refillable three times, Ned. By the way, how was the bridal suite at the Samarkand Motel 6?"

If the patient exclaims, "You have a good memory! How did you remember that?" I usually confess that I'd written it down. That doesn't seem to offend anybody; instead, they're somewhat pleased to have a stranger show some interest in their nonmedical lives. I do it to make people comfortable and to get to know them a bit, because many of them come back at odd intervals over the course of many years.

I have another reason, too—a dark secret now revealed here for the first time: I occasionally find patients' stories even more riveting than the diagnostic and therapeutic challenges posed by their rashes and skin growths. There, I said it.

Outside the office, I'm even more lost when greeted by patients who know me. By now, I've been around long enough that it's hard to go to the grocery or the gym or to just walk down the street without running into someone who stares, grins, and says, "Dr. Rockoff—is that you?"

I usually admit that it is and smile brightly in apparent recognition, keeping a keen eye out for an escape route before further conversation can unmask my ignorance of who the dickens they are. ("You know me! The one with the rash!") My father, well known in our hometown, was often hailed by strangers. He always smiled heartily and waved back. "Who was that?" I'd ask. "I have no idea," he'd say. "But they seem to know me, so I wave."

Of course, it's hard to recognize people out of context. I think my patients should have an easier time remembering me than I do them; after all, there are so many of them and just one of me. For the most part that's true, but some folks are just better at remembering than others are.

"Nice to meet you, Mr. Steele."

"I met you already."

"Well, actually, the one time you were here before, you saw my associate Henrietta."

"You know, you're right—it was a lady!"

Glad we straightened that out.

Good morning, Mr. Nesia. I see you haven't been here in 15 years."

"I was never here before."

"Forgive me—aren't you Alford M. Nesia, address 36 Endive Gardens Avenue, Boxboro, date of birth April 5, 1954?"

"Yes."

"In that case, you were here in August of 1991."

"I did see a dermatologist once, come to think of it. Was that you?"

It's always nice to know you've made a strong impression. Of course, forgetfulness works both ways:

"Nice to meet you, Ms. Jones."

"I saw you last month, Doctor."

Ouch. This usually happens when my staff checks in an old patient as a new one. Sometimes they haven't been able to find the patient's name in the computer (misspellings, data loss, a 20-year absence, whatever). In other cases, the patient has come in with a child or other relative but never registered under his or her own name. I have a pretty good memory, but without a chart, I'm mostly lost.

Unrecognized patients often make allowances. "You have so many patients, Doctor, you can't possibly remember them all." True enough.

I do try, though. People are often flattered when recognized, offended when they're not. (That's why politicians make such a point of remembering everyone.) Knowing who people are is a good start, but recollecting personal details is even better. I often note such details in the chart, whether they're germane to skin complaints or not. The patient may have started a new job, graduated college, bought a condo, planned a honeymoon in Uzbekistan.

When notes jog my memory about such things, I deftly slip in a personal reference while writing a prescription. "The doxycycline is refillable three times, Ned. By the way, how was the bridal suite at the Samarkand Motel 6?"

If the patient exclaims, "You have a good memory! How did you remember that?" I usually confess that I'd written it down. That doesn't seem to offend anybody; instead, they're somewhat pleased to have a stranger show some interest in their nonmedical lives. I do it to make people comfortable and to get to know them a bit, because many of them come back at odd intervals over the course of many years.

I have another reason, too—a dark secret now revealed here for the first time: I occasionally find patients' stories even more riveting than the diagnostic and therapeutic challenges posed by their rashes and skin growths. There, I said it.

Outside the office, I'm even more lost when greeted by patients who know me. By now, I've been around long enough that it's hard to go to the grocery or the gym or to just walk down the street without running into someone who stares, grins, and says, "Dr. Rockoff—is that you?"

I usually admit that it is and smile brightly in apparent recognition, keeping a keen eye out for an escape route before further conversation can unmask my ignorance of who the dickens they are. ("You know me! The one with the rash!") My father, well known in our hometown, was often hailed by strangers. He always smiled heartily and waved back. "Who was that?" I'd ask. "I have no idea," he'd say. "But they seem to know me, so I wave."

Of course, it's hard to recognize people out of context. I think my patients should have an easier time remembering me than I do them; after all, there are so many of them and just one of me. For the most part that's true, but some folks are just better at remembering than others are.

"Nice to meet you, Mr. Steele."

"I met you already."

"Well, actually, the one time you were here before, you saw my associate Henrietta."

"You know, you're right—it was a lady!"

Glad we straightened that out.

Good morning, Mr. Nesia. I see you haven't been here in 15 years."

"I was never here before."

"Forgive me—aren't you Alford M. Nesia, address 36 Endive Gardens Avenue, Boxboro, date of birth April 5, 1954?"

"Yes."

"In that case, you were here in August of 1991."

"I did see a dermatologist once, come to think of it. Was that you?"

It's always nice to know you've made a strong impression. Of course, forgetfulness works both ways:

"Nice to meet you, Ms. Jones."

"I saw you last month, Doctor."

Ouch. This usually happens when my staff checks in an old patient as a new one. Sometimes they haven't been able to find the patient's name in the computer (misspellings, data loss, a 20-year absence, whatever). In other cases, the patient has come in with a child or other relative but never registered under his or her own name. I have a pretty good memory, but without a chart, I'm mostly lost.

Unrecognized patients often make allowances. "You have so many patients, Doctor, you can't possibly remember them all." True enough.

I do try, though. People are often flattered when recognized, offended when they're not. (That's why politicians make such a point of remembering everyone.) Knowing who people are is a good start, but recollecting personal details is even better. I often note such details in the chart, whether they're germane to skin complaints or not. The patient may have started a new job, graduated college, bought a condo, planned a honeymoon in Uzbekistan.

When notes jog my memory about such things, I deftly slip in a personal reference while writing a prescription. "The doxycycline is refillable three times, Ned. By the way, how was the bridal suite at the Samarkand Motel 6?"

If the patient exclaims, "You have a good memory! How did you remember that?" I usually confess that I'd written it down. That doesn't seem to offend anybody; instead, they're somewhat pleased to have a stranger show some interest in their nonmedical lives. I do it to make people comfortable and to get to know them a bit, because many of them come back at odd intervals over the course of many years.

I have another reason, too—a dark secret now revealed here for the first time: I occasionally find patients' stories even more riveting than the diagnostic and therapeutic challenges posed by their rashes and skin growths. There, I said it.

Outside the office, I'm even more lost when greeted by patients who know me. By now, I've been around long enough that it's hard to go to the grocery or the gym or to just walk down the street without running into someone who stares, grins, and says, "Dr. Rockoff—is that you?"

I usually admit that it is and smile brightly in apparent recognition, keeping a keen eye out for an escape route before further conversation can unmask my ignorance of who the dickens they are. ("You know me! The one with the rash!") My father, well known in our hometown, was often hailed by strangers. He always smiled heartily and waved back. "Who was that?" I'd ask. "I have no idea," he'd say. "But they seem to know me, so I wave."

Of course, it's hard to recognize people out of context. I think my patients should have an easier time remembering me than I do them; after all, there are so many of them and just one of me. For the most part that's true, but some folks are just better at remembering than others are.

"Nice to meet you, Mr. Steele."

"I met you already."

"Well, actually, the one time you were here before, you saw my associate Henrietta."

"You know, you're right—it was a lady!"

Glad we straightened that out.

• Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
• At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."

What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.

She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.

Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.

The decision that people make about What Belongs applies to acquired lesions as well.

Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?

Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.

Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?

No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."

The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:

• General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
• System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
• Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."

Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.

In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.

They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.

This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.

The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.

• Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
• At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."

What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.

She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.

Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.

The decision that people make about What Belongs applies to acquired lesions as well.

Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?

Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.

Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?

No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."

The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:

• General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
• System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
• Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."

Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.

In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.

They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.

This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.

The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.

• Two PhD astronomers bring 2-year-old Tyco to show me the mole on his palm. I pronounce it benign and tell the little fellow, "Your boo-boo is okay." Tyco's face darkens. "No boo-boo!" he yells. "No boo-boo!"
• At 52, Hortense has many facial brown spots for me to laser off. "Don't take off that one!" she says. "It's always been there. I like it."

What do these patients have in common? Hortense likes one spot, because it's always been there (or so she thinks). Therefore, it is Hortense.

She wants the other spots off for the reciprocal reason: they are Not-Hortense. They came later, and they don't belong.

Little Tyco demonstrates how early the Self/Nonself sense can develop. Already, at the age of 2, he knows the spot on his palm is not a boo-boo. To be precise, a boo-boo is something that's wrong, that shouldn't be there. He knows his mole should be there. It is Tyco. When Tyco grows up, he will never have it removed if he can help it.

The decision that people make about What Belongs applies to acquired lesions as well.

Consider Carmine, a cardiologist who takes off his shirt to reveal a big, black melanoma right in the middle of his back. Not only that—his wife is with him! When spouses often send each other in for trivial changes, how could these two have both overlooked something so blatant?

Simple. "That's been there for years," says Carmine. His wife agrees. At some point, they both decided the spot was part of Carmine. From then on, they stopped looking. It just belonged there.

Or take Perry. He asks me to zap a tiny spot on his nose. Two years later, he shows up with a big, ulcerated basal cell. Is he blind? Are his friends?

No. "You told me it was okay," he points out, "so I assumed it was supposed to do that."

The Self/Nonself dichotomy actually applies not just to lesions, congenital or acquired, but to all sorts of symptoms. People develop a strong sense of their Constitution, a kind of Health Personality that is uniquely and recognizably their own. You can hear this in the following kinds of statements people make about themselves:

• General. "I'm the kind of person who… (gets sick all the time/is healthy as a horse)."
• System specific. "I've always had… (good skin/terrible skin, beautiful hair/thin hair)."
• Disease specific. "Why should I have acne? I never had it before!" "Why should I get eczema? I don't get rashes." "Oh, I figured it was eczema. I've always had skin issues."

Patients say things like this all the time. In our medical view of disease, anything can happen to anyone. By contrast, patients make sense of things by deciding that some things happen to certain kinds of people. That's just them. What's worrisome is when something happens to someone who it shouldn't happen to. That's just not them.

In other words, people somehow develop a deep, unshakable sense of what kind of individuals they are.

They might overlook abnormalities for long periods, sometimes to their detriment, just because in their own minds, these signs or symptoms belong there. What worries them is any deviation or something new that shouldn't be there—a new spot, an unaccustomed itch, and so on.

This Self/Nonself distinction is one of many reasons that we can't count on our patients to report the signs and symptoms that are important to us. If they think, "Hey, that's just Me," they might keep quiet.

The philosopher tells us: Know thyself. Our patients do. We should know ourselves—and them, too.

My first exposure to clinical dermatology consisted of a month of Friday morning skin clinics during my second year of pediatric residency. Then, as now, skin disease was judged too unimportant to be taught to medical students.

Three volunteer dermatologists slumming from Manhattan supervised—two men and a woman. Their stylish dress clashed with the dingy decor of a Bronx city hospital OPD. Between patients, they spoke of cars.

My first patient sat on a gurney at the back of an alcove separated from the corridor by a curtain. Because I had no idea what she had, my presentation must have been brief. The three dermatologists followed me back in and took a casual look. Turning to leave, one of the men said, "Pityriasis rubra pilaris." The others nodded, exiting the alcove.

I was astonished. How could they just look at something and know what it was? Much later, I learned their twin secrets:

▸ Knowing from experience.

▸ Making up what you don't know.

What prompted this small reminiscence was a recent essay in the New England Journal of Medicine, "The Demise of the Physical Exam" (2006;354:548–51). In the essay, Dr. Sandeep Jauhar recounts a medical school incident in which he missed an aortic dissection by failing to note that the patient's blood pressure was higher on one side than the other. The way he remembers physical diagnosis instruction sounded familiar: "The preceptor was an intense but likable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. … Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it."

Dr. Jauhar notes several reasons for this dismissal, including lack of time to do a proper physical and the noisy distractions of a hospital milieu. The most important reason, however, is the fact that diagnostic tests just do a better job at making diagnoses. This is true even in comparing chest x-rays with auscultation, and new diagnostic technology of mind-bending sophistication only makes the disparity more glaring. Compared with an MRI, a physical exam seems like something from grandma's attic.

One field of medicine remains, however, where physical examination is alive and well: ours. Most dermatologists with any experience do every day what my long-ago preceptors so amazed me with: walk in, look, diagnose. We don't do a lot of tests. We don't have a lot of tests to do.

Last week, I recorded patients' diagnoses and lab tests on a random day. Of 46 patients, 23 had rashes (acne, psoriasis, and so forth); 5 had bacterial or fungal skin infections; 5 had warts; 11 had lesions of some sort; and 2 had cosmetic-related questions.

The lab test tally for that day was one bacterial skin culture, one fungus culture, one KOH prep, blood tests for a patient taking isotretinoin, and three biopsies.

This seems typical of one of our days. Most of the time, we glance and know at once what we're dealing with. (Managing it is another story.)

For every lesion we biopsy, people show us 20 we diagnose by inspection (visual or dermoscopic). Rashes are mostly clear cut. When they aren't, we biopsy. (And how often does the biopsy of a rash give us a decisive answer?) For many infections, cultures are confirmatory, if not redundant. Drug rashes? Viral exanthems? Clinical diagnoses.

Medical students find all this as weird as I did when first exposed to it. They're so used to watching people order tests—to diagnose, placate senior staff, or ward off phantom attorneys—that their clinical skills atrophy before they develop; they lose it even before they use it. When I ask my students what their impression is of a rash, their eyes widen in a silent plea: You mean I should know just by looking?

Well, yes. As is true of any skill, you can develop it, with instruction and practice.

Without a dermatology elective in school, many physicians carry this primal fear of skin disease indefinitely. "Skin makes me nervous," they tell patients. "See the dermatologist." They think our skills are a little occult.

We dermatologists shouldn't take too much credit for our archaic clinical virtuosity, such as it is. To a large extent, we don't rely on tests because we don't have tests to rely on. If we had more crutches, we would lean on them as much as anyone else does. Our patients would insist.

Meantime, however, we practice in a manner that is alarmingly similar to the way our remote clinical ancestors did.

We walk in, look, and know from experience what's going on. And what we don't know, we make up, assigning a provisional label in the hope that time will clarify things and bail us out—which it often does.

For our small corner of the medical universe, therefore, reports of the demise of the physical exam have been greatly exaggerated.

My first exposure to clinical dermatology consisted of a month of Friday morning skin clinics during my second year of pediatric residency. Then, as now, skin disease was judged too unimportant to be taught to medical students.

Three volunteer dermatologists slumming from Manhattan supervised—two men and a woman. Their stylish dress clashed with the dingy decor of a Bronx city hospital OPD. Between patients, they spoke of cars.

My first patient sat on a gurney at the back of an alcove separated from the corridor by a curtain. Because I had no idea what she had, my presentation must have been brief. The three dermatologists followed me back in and took a casual look. Turning to leave, one of the men said, "Pityriasis rubra pilaris." The others nodded, exiting the alcove.

I was astonished. How could they just look at something and know what it was? Much later, I learned their twin secrets:

▸ Knowing from experience.

▸ Making up what you don't know.

What prompted this small reminiscence was a recent essay in the New England Journal of Medicine, "The Demise of the Physical Exam" (2006;354:548–51). In the essay, Dr. Sandeep Jauhar recounts a medical school incident in which he missed an aortic dissection by failing to note that the patient's blood pressure was higher on one side than the other. The way he remembers physical diagnosis instruction sounded familiar: "The preceptor was an intense but likable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. … Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it."

Dr. Jauhar notes several reasons for this dismissal, including lack of time to do a proper physical and the noisy distractions of a hospital milieu. The most important reason, however, is the fact that diagnostic tests just do a better job at making diagnoses. This is true even in comparing chest x-rays with auscultation, and new diagnostic technology of mind-bending sophistication only makes the disparity more glaring. Compared with an MRI, a physical exam seems like something from grandma's attic.

One field of medicine remains, however, where physical examination is alive and well: ours. Most dermatologists with any experience do every day what my long-ago preceptors so amazed me with: walk in, look, diagnose. We don't do a lot of tests. We don't have a lot of tests to do.

Last week, I recorded patients' diagnoses and lab tests on a random day. Of 46 patients, 23 had rashes (acne, psoriasis, and so forth); 5 had bacterial or fungal skin infections; 5 had warts; 11 had lesions of some sort; and 2 had cosmetic-related questions.

The lab test tally for that day was one bacterial skin culture, one fungus culture, one KOH prep, blood tests for a patient taking isotretinoin, and three biopsies.

This seems typical of one of our days. Most of the time, we glance and know at once what we're dealing with. (Managing it is another story.)

For every lesion we biopsy, people show us 20 we diagnose by inspection (visual or dermoscopic). Rashes are mostly clear cut. When they aren't, we biopsy. (And how often does the biopsy of a rash give us a decisive answer?) For many infections, cultures are confirmatory, if not redundant. Drug rashes? Viral exanthems? Clinical diagnoses.

Medical students find all this as weird as I did when first exposed to it. They're so used to watching people order tests—to diagnose, placate senior staff, or ward off phantom attorneys—that their clinical skills atrophy before they develop; they lose it even before they use it. When I ask my students what their impression is of a rash, their eyes widen in a silent plea: You mean I should know just by looking?

Well, yes. As is true of any skill, you can develop it, with instruction and practice.

Without a dermatology elective in school, many physicians carry this primal fear of skin disease indefinitely. "Skin makes me nervous," they tell patients. "See the dermatologist." They think our skills are a little occult.

We dermatologists shouldn't take too much credit for our archaic clinical virtuosity, such as it is. To a large extent, we don't rely on tests because we don't have tests to rely on. If we had more crutches, we would lean on them as much as anyone else does. Our patients would insist.

Meantime, however, we practice in a manner that is alarmingly similar to the way our remote clinical ancestors did.

We walk in, look, and know from experience what's going on. And what we don't know, we make up, assigning a provisional label in the hope that time will clarify things and bail us out—which it often does.

For our small corner of the medical universe, therefore, reports of the demise of the physical exam have been greatly exaggerated.

My first exposure to clinical dermatology consisted of a month of Friday morning skin clinics during my second year of pediatric residency. Then, as now, skin disease was judged too unimportant to be taught to medical students.

Three volunteer dermatologists slumming from Manhattan supervised—two men and a woman. Their stylish dress clashed with the dingy decor of a Bronx city hospital OPD. Between patients, they spoke of cars.

My first patient sat on a gurney at the back of an alcove separated from the corridor by a curtain. Because I had no idea what she had, my presentation must have been brief. The three dermatologists followed me back in and took a casual look. Turning to leave, one of the men said, "Pityriasis rubra pilaris." The others nodded, exiting the alcove.

I was astonished. How could they just look at something and know what it was? Much later, I learned their twin secrets:

▸ Knowing from experience.

▸ Making up what you don't know.

What prompted this small reminiscence was a recent essay in the New England Journal of Medicine, "The Demise of the Physical Exam" (2006;354:548–51). In the essay, Dr. Sandeep Jauhar recounts a medical school incident in which he missed an aortic dissection by failing to note that the patient's blood pressure was higher on one side than the other. The way he remembers physical diagnosis instruction sounded familiar: "The preceptor was an intense but likable oncology fellow who was clearly ambivalent about the value of the skills he was teaching. … Even as he went through the motions of teaching physical diagnosis, he appeared to be dismissing it."

Dr. Jauhar notes several reasons for this dismissal, including lack of time to do a proper physical and the noisy distractions of a hospital milieu. The most important reason, however, is the fact that diagnostic tests just do a better job at making diagnoses. This is true even in comparing chest x-rays with auscultation, and new diagnostic technology of mind-bending sophistication only makes the disparity more glaring. Compared with an MRI, a physical exam seems like something from grandma's attic.

One field of medicine remains, however, where physical examination is alive and well: ours. Most dermatologists with any experience do every day what my long-ago preceptors so amazed me with: walk in, look, diagnose. We don't do a lot of tests. We don't have a lot of tests to do.

Last week, I recorded patients' diagnoses and lab tests on a random day. Of 46 patients, 23 had rashes (acne, psoriasis, and so forth); 5 had bacterial or fungal skin infections; 5 had warts; 11 had lesions of some sort; and 2 had cosmetic-related questions.

The lab test tally for that day was one bacterial skin culture, one fungus culture, one KOH prep, blood tests for a patient taking isotretinoin, and three biopsies.

This seems typical of one of our days. Most of the time, we glance and know at once what we're dealing with. (Managing it is another story.)

For every lesion we biopsy, people show us 20 we diagnose by inspection (visual or dermoscopic). Rashes are mostly clear cut. When they aren't, we biopsy. (And how often does the biopsy of a rash give us a decisive answer?) For many infections, cultures are confirmatory, if not redundant. Drug rashes? Viral exanthems? Clinical diagnoses.

Medical students find all this as weird as I did when first exposed to it. They're so used to watching people order tests—to diagnose, placate senior staff, or ward off phantom attorneys—that their clinical skills atrophy before they develop; they lose it even before they use it. When I ask my students what their impression is of a rash, their eyes widen in a silent plea: You mean I should know just by looking?

Well, yes. As is true of any skill, you can develop it, with instruction and practice.

Without a dermatology elective in school, many physicians carry this primal fear of skin disease indefinitely. "Skin makes me nervous," they tell patients. "See the dermatologist." They think our skills are a little occult.

We dermatologists shouldn't take too much credit for our archaic clinical virtuosity, such as it is. To a large extent, we don't rely on tests because we don't have tests to rely on. If we had more crutches, we would lean on them as much as anyone else does. Our patients would insist.

Meantime, however, we practice in a manner that is alarmingly similar to the way our remote clinical ancestors did.

We walk in, look, and know from experience what's going on. And what we don't know, we make up, assigning a provisional label in the hope that time will clarify things and bail us out—which it often does.

For our small corner of the medical universe, therefore, reports of the demise of the physical exam have been greatly exaggerated.

My pager went off Saturday night. Susan was in a panic. "I couldn't log onto the iPledge Web site!" she cried. "I called their number and waited 40 minutes, and they told me you hadn't confirmed contraceptive counseling. If I don't get the medicine Monday, I'll be locked out for a month!"

I know an emergency when I hear one. Susan had already taken isotretinoin for a month, so a 30-day holiday would not do. Springing into action, I logged onto the iPledge Web site, located Susan, and pressed the "Confirm Patient Counseling" tab to verify that I'd told her not to get pregnant. I did that at her visit Thursday, noting that the pregnancy test from Tuesday was negative. No dice. The error message read, "Not enough time has elapsed."

Not enough time? Not enough time for what?

I called the 866 number and had to wait just a few moments, listening to the grating background music, before a human being picked up. I gave her my DEA number.

"I need your date of personal significance," she said.

Other Web sites use secondary passwords you can actually recall, like your mother's maiden name. "I don't know my date of personal significance," I said.

"Would you like to guess?" she said. I guessed my birthday. Wrong.

"We can't speak to providers who don't know their date of personal significance," she said, "unless they answer the phone in their office. Are you in your office?"

"It's 10 o'clock Saturday night," I said. "I'm home."

"Then I can't help you," she said.

"For heaven's sake," I said, "if you call my office, the automated attendant will identify my name. …" Just then I found the memo in my Palm. Of course that was the significant date I'd picked: 9/11/01. Catastrophe.

Now she could help me. Only she couldn't. I stated my problem. "This patient had express registration," she said. "There's no waiting period. It must be a system problem. I'll transfer you to technical support."

Now I had my chance to spend 40 minutes listening every 60 seconds to, "Your call is important to us. Someone will be with you shortly." Eventually someone was.

"May I help you?"

I certainly hoped so.

"I'm exhausted," she said. "I've been working 12 hours, 7 days in a row. And it's busy!"

I commiserated and restated my problem. She put me on hold, then returned. "This patient had express registration," she said. "There's no waiting period. This shouldn't happen."

I agreed.

"'Not enough time has elapsed,'" she read. "What does that mean? It makes no sense!"

"Good point," I concurred.

She tried entering different dates. "Aha!" she said. "I got it to work!"

"What did you do?"

"The contraceptive counseling has to be before the pregnancy test," she said, "Otherwise the system won't take it."

"Does that mean that if my patient takes a pregnancy test Monday and I see her on Wednesday and counsel her then, the counseling doesn't count?" I asked.

"That's a medical question," she said. "I'm not authorized to answer medical questions about the actual program. I'm technical. I just know how to make the Web site work."

"Is the patient all set?" I asked.

"All set!" she said. I told her to go home and get some rest.

I hung up, pleased with another useful job under my belt.

I celebrated too soon, though. As we all know by now, iPledge drollery has degenerated to disaster. Getting Susan her medicine took 3 more days of calls and listening to, "We are experiencing a high call volume. Peak times are 9:00 a.m. until noon. Please call back another time." This message played from 9:00 a.m. to midnight, followed by disconnection. Click. You're dead.

Things will no doubt get better in time. They may expand the number of operators from four to six. Someone familiar with English will change all the "who's" on the Web site to "whose." And maybe they'll figure out a way not to require monthly counseling for males. ("Don't give your pills to pregnant women!" "Take prenatal vitamins!")

They may even improve the music. When you're on hold, that music you are hearing oompahing and sawing away in the background is Mozart's "A Musical Joke."

Please tell me, what warped bureaucrat would choose, from the whole universe of musical possibilities, Mozart's purposely annoying send-up of incompetent composers and instrumentalists?

At least we know whom the joke's on, don't we? Our patients and us.

My pager went off Saturday night. Susan was in a panic. "I couldn't log onto the iPledge Web site!" she cried. "I called their number and waited 40 minutes, and they told me you hadn't confirmed contraceptive counseling. If I don't get the medicine Monday, I'll be locked out for a month!"

I know an emergency when I hear one. Susan had already taken isotretinoin for a month, so a 30-day holiday would not do. Springing into action, I logged onto the iPledge Web site, located Susan, and pressed the "Confirm Patient Counseling" tab to verify that I'd told her not to get pregnant. I did that at her visit Thursday, noting that the pregnancy test from Tuesday was negative. No dice. The error message read, "Not enough time has elapsed."

Not enough time? Not enough time for what?

I called the 866 number and had to wait just a few moments, listening to the grating background music, before a human being picked up. I gave her my DEA number.

"I need your date of personal significance," she said.

Other Web sites use secondary passwords you can actually recall, like your mother's maiden name. "I don't know my date of personal significance," I said.

"Would you like to guess?" she said. I guessed my birthday. Wrong.

"We can't speak to providers who don't know their date of personal significance," she said, "unless they answer the phone in their office. Are you in your office?"

"It's 10 o'clock Saturday night," I said. "I'm home."

"Then I can't help you," she said.

"For heaven's sake," I said, "if you call my office, the automated attendant will identify my name. …" Just then I found the memo in my Palm. Of course that was the significant date I'd picked: 9/11/01. Catastrophe.

Now she could help me. Only she couldn't. I stated my problem. "This patient had express registration," she said. "There's no waiting period. It must be a system problem. I'll transfer you to technical support."

Now I had my chance to spend 40 minutes listening every 60 seconds to, "Your call is important to us. Someone will be with you shortly." Eventually someone was.

"May I help you?"

I certainly hoped so.

"I'm exhausted," she said. "I've been working 12 hours, 7 days in a row. And it's busy!"

I commiserated and restated my problem. She put me on hold, then returned. "This patient had express registration," she said. "There's no waiting period. This shouldn't happen."

I agreed.

"'Not enough time has elapsed,'" she read. "What does that mean? It makes no sense!"

"Good point," I concurred.

She tried entering different dates. "Aha!" she said. "I got it to work!"

"What did you do?"

"The contraceptive counseling has to be before the pregnancy test," she said, "Otherwise the system won't take it."

"Does that mean that if my patient takes a pregnancy test Monday and I see her on Wednesday and counsel her then, the counseling doesn't count?" I asked.

"That's a medical question," she said. "I'm not authorized to answer medical questions about the actual program. I'm technical. I just know how to make the Web site work."

"Is the patient all set?" I asked.

"All set!" she said. I told her to go home and get some rest.

I hung up, pleased with another useful job under my belt.

I celebrated too soon, though. As we all know by now, iPledge drollery has degenerated to disaster. Getting Susan her medicine took 3 more days of calls and listening to, "We are experiencing a high call volume. Peak times are 9:00 a.m. until noon. Please call back another time." This message played from 9:00 a.m. to midnight, followed by disconnection. Click. You're dead.

Things will no doubt get better in time. They may expand the number of operators from four to six. Someone familiar with English will change all the "who's" on the Web site to "whose." And maybe they'll figure out a way not to require monthly counseling for males. ("Don't give your pills to pregnant women!" "Take prenatal vitamins!")

They may even improve the music. When you're on hold, that music you are hearing oompahing and sawing away in the background is Mozart's "A Musical Joke."

Please tell me, what warped bureaucrat would choose, from the whole universe of musical possibilities, Mozart's purposely annoying send-up of incompetent composers and instrumentalists?

At least we know whom the joke's on, don't we? Our patients and us.

My pager went off Saturday night. Susan was in a panic. "I couldn't log onto the iPledge Web site!" she cried. "I called their number and waited 40 minutes, and they told me you hadn't confirmed contraceptive counseling. If I don't get the medicine Monday, I'll be locked out for a month!"

I know an emergency when I hear one. Susan had already taken isotretinoin for a month, so a 30-day holiday would not do. Springing into action, I logged onto the iPledge Web site, located Susan, and pressed the "Confirm Patient Counseling" tab to verify that I'd told her not to get pregnant. I did that at her visit Thursday, noting that the pregnancy test from Tuesday was negative. No dice. The error message read, "Not enough time has elapsed."

Not enough time? Not enough time for what?

I called the 866 number and had to wait just a few moments, listening to the grating background music, before a human being picked up. I gave her my DEA number.

"I need your date of personal significance," she said.

Other Web sites use secondary passwords you can actually recall, like your mother's maiden name. "I don't know my date of personal significance," I said.

"Would you like to guess?" she said. I guessed my birthday. Wrong.

"We can't speak to providers who don't know their date of personal significance," she said, "unless they answer the phone in their office. Are you in your office?"

"It's 10 o'clock Saturday night," I said. "I'm home."

"Then I can't help you," she said.

"For heaven's sake," I said, "if you call my office, the automated attendant will identify my name. …" Just then I found the memo in my Palm. Of course that was the significant date I'd picked: 9/11/01. Catastrophe.

Now she could help me. Only she couldn't. I stated my problem. "This patient had express registration," she said. "There's no waiting period. It must be a system problem. I'll transfer you to technical support."

Now I had my chance to spend 40 minutes listening every 60 seconds to, "Your call is important to us. Someone will be with you shortly." Eventually someone was.

"May I help you?"

I certainly hoped so.

"I'm exhausted," she said. "I've been working 12 hours, 7 days in a row. And it's busy!"

I commiserated and restated my problem. She put me on hold, then returned. "This patient had express registration," she said. "There's no waiting period. This shouldn't happen."

I agreed.

"'Not enough time has elapsed,'" she read. "What does that mean? It makes no sense!"

"Good point," I concurred.

She tried entering different dates. "Aha!" she said. "I got it to work!"

"What did you do?"

"The contraceptive counseling has to be before the pregnancy test," she said, "Otherwise the system won't take it."

"Does that mean that if my patient takes a pregnancy test Monday and I see her on Wednesday and counsel her then, the counseling doesn't count?" I asked.

"That's a medical question," she said. "I'm not authorized to answer medical questions about the actual program. I'm technical. I just know how to make the Web site work."

"Is the patient all set?" I asked.

"All set!" she said. I told her to go home and get some rest.

I hung up, pleased with another useful job under my belt.

I celebrated too soon, though. As we all know by now, iPledge drollery has degenerated to disaster. Getting Susan her medicine took 3 more days of calls and listening to, "We are experiencing a high call volume. Peak times are 9:00 a.m. until noon. Please call back another time." This message played from 9:00 a.m. to midnight, followed by disconnection. Click. You're dead.

Things will no doubt get better in time. They may expand the number of operators from four to six. Someone familiar with English will change all the "who's" on the Web site to "whose." And maybe they'll figure out a way not to require monthly counseling for males. ("Don't give your pills to pregnant women!" "Take prenatal vitamins!")

They may even improve the music. When you're on hold, that music you are hearing oompahing and sawing away in the background is Mozart's "A Musical Joke."

Please tell me, what warped bureaucrat would choose, from the whole universe of musical possibilities, Mozart's purposely annoying send-up of incompetent composers and instrumentalists?

At least we know whom the joke's on, don't we? Our patients and us.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

It's been said that 36 plot lines cover every dramatic situation. These include "Revenge: Avenger, Criminal" (no. 3); "Familial Hatred: Two Family Members Who Hate Each Other" (no. 13); and "Adultery: Deceived Spouse, Two Adulterers" (no. 25).

On the list of what motivates people to visit doctors, there is also a limited number of what you might call master narratives. As applied to dermatology, the following are some examples:

▸ The beginning of the end. My symptom, however slight, means the start of a process that will result in death.

▸ Family ties. My relative who had this problem suffered or came to a bad end, and since I take after him in my looks, personality, and skin type, I will, too.

▸ Unclean! Unclean! This rash means I am contaminated and will have to hide from polite society.

Finding which of these applies to a given patient is useful, because it helps explain why she actually showed up as opposed to why she says she has. A directed question or two plus a few seconds of open-ended conversation usually reveal these master narratives, such as the following:

▸ "My aunt had exactly the same mole, and it turned cancerous and she died of brain cancer."

▸ "I haven't been to yoga in a year, because you lay right next to the next person's foot, and I can't have someone else stare at this ugly plantar wart."

Master narratives are easy to spot; there are just a few, and they apply broadly. Most every patient turns out to be worried that he is dying, allergic, contagious, or ugly. It's therefore helpful to address not just specific symptoms, but rather their implications, by saying that psoriasis is hereditary but doesn't manifest itself the same way in every family member, that warts and fungi are not as catchy as all that, and so forth.

More tricky are what I would term private narratives. These are a kind of subplot, not significant to all patients, but just to a particular one.

These narratives draw attention to concerns you might not guess unless you spend a couple of extra minutes (that's really all it takes) to hear people tell their own story. Here are some examples from my own stock:

▸ Robert complains of a merciless itch that affects just his chest. Itchy people fill our days, of course; some have eczema, some scabies, others anxiety. But why did the itch affect just his chest? Well, the previous October Robert almost died of pericarditis. Just as many women worry that anything on skin near the breast may mean breast cancer, patients in general often ascribe symptoms on the skin to the organs they think are underneath them. Not everybody with a chest itch thinks he has recurrent pericarditis though, just Robert.

▸ Phil has a seborrheic keratosis sticking out of his scalp. Everybody worries about a new or changing growth, but the concern is not always due to the growth being situated right next to a scar from epidural hematoma surgery, as in Phil's case.

▸ Sally has warts on her left shin. She somehow seems more worried than most people about catchiness and spread via shaving. It turns out that Susie, Sally's sister with whom she is very close, had a melanoma removed from her left shin. Melanoma may not be on our wart differential, but it is on Sally's.

▸ Jeff was at a summer barbecue, netting an impressive collection of juicy mosquito bites on his legs. Why is he so anxious about them? Five years earlier he had vasculitis on his legs, and the bites remind him of that episode. Palpable purpura is a pretty exotic thing for a layman to worry about, but not a layman who had a memorably bad time with it.

▸ The hemangioma on Ruth's face, present for years, looks banal, but not to Ruth. Her friend had internal hemangiomas that needed MRIs and surgery.

▸ Mike has a few folliculitis lesions in his groin area. He also has self-described "Irish-Catholic guilt" and a 92-year-old father recovering from a transurethral resection of the prostate, who Mike has been caring for and to whom he fears he's spread the folliculitis.

▸ Henry has extra pigment on his penis. Is he worried about an STD? Actually, no. He's worried because his grandfather "had polio or something and got mottled all over."

We all have the same story, yet everyone has his own. It's a good idea to pay attention to both.

If I weren't allergic to the word, I'd call that approach holistic.

Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.

One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.

Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.

But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.

Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.

Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.

My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.

"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"

I was supposed to answer yes, that was bad.

Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.

Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.

QED: scabies.

And if it isn't, hey, what's the worst that could happen?

Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.

The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."

All agree that close physical contact is the most likely source of scabies transmission.

I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.

The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.

It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.

Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.

Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.

One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.

Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.

But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.

Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.

Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.

My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.

"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"

I was supposed to answer yes, that was bad.

Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.

Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.

QED: scabies.

And if it isn't, hey, what's the worst that could happen?

Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.

The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."

All agree that close physical contact is the most likely source of scabies transmission.

I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.

The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.

It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.

Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.

Once upon a time, in the little village of Dunkelkratz, there lived a woman named Mabel. Mabel taught third grade at Groovy Acres Elementary School.

One day Mabel had an itch. Nobody at home was itchy, just Mabel. She went to her ob.gyn., Dr. Livious, who told Mabel she had scabies, a nasty bug that burrows into the skin. Mabel felt very dirty, even though she showered every single day. The nurse sealed off the room where Dr. Livious had examined Mabel and disinfected it.

Mabel called her principal, Dr. Pollicy, and told him she couldn't come to Groovy Acres that day because she had scabies. Mabel got the scabies medicine Dr. Livious prescribed at Frendly Farmacy and rubbed it all over her body. Then she bought insecticide at the Happy Pliers hardware store and sprayed it onto all the walls in her apartment. After that Mabel took all her coats and dresses to Mr. Spotless, the dry cleaner, who promised that in 3 days Mabel could pick them up for $750.

But Mabel kept itching, so she visited Dr. Skrepping, her dermatologist. Dr. Skrepping examined Mabel, asked about the other people in her house, and told her she didn't have scabies. He suggested that she not apply the medicine to her skin for a fifth time and also that she wipe the insecticide off her walls.

Mabel called Groovy Acres right away to share the good news. Dr. Pollicy told her that he had already sent letters to the parents of all the families in Mabel's class to warn them that their children had been exposed to scabies and should see their doctors right away.

Soon afterward, Frendly Farmacy ran out of scabies medicine, the Happy Pliers ran out of insecticide, and Mr. Spotless the dry cleaner closed and retired to the Cayman Islands.

My most memorable teacher in medical school was a gravel-voiced ob.gyn. professor who liked to specify the consequences of mistakes.

"What's the worst that could happen if you did that?" he would growl. "The patient could die, Rockoff," he would say. "Is that bad?"

I was supposed to answer yes, that was bad.

Many mistakes have consequences, but there seems to be a widespread notion that the costs of getting a mere skin disease wrong don't amount to much. The Mabels of the world—you've met them, too—might say otherwise.

Here is what happens when an itchy Mabel visits a walk-in clinic: The doctor presumes that she is sexually active because she is breathing. He identifies her 3-inch linear excoriations as "burrows." He learns that she itches more at night.

QED: scabies.

And if it isn't, hey, what's the worst that could happen?

Actually, plenty: a gratuitous feeling of being unhygienic, unnecessary use of insecticides, ruinous dry-cleaning bills. And, oh yes—if it isn't scabies, not getting better.

The role of fomites in spreading scabies is not completely clear. Some sources say mites can live off the body for a couple of days; others, that fomites are "not very important."

All agree that close physical contact is the most likely source of scabies transmission.

I recall reading years ago in Kenneth Mellanby's "Scabies" that British army researchers in World War II had subjects sleep in beds where scabies sufferers had slept the night before. Few contracted it.

The upshot is that, although just thinking about scabies makes people feel repulsive and itchy, it's really hard to catch mites from shaking hands, hanging your coat next to someone else's in a closet, or sitting on fresh table paper in an exam room just vacated by a person whom somebody else thinks may have scabies.

It would be unrealistic to expect busy primary or urgent care physicians to become adept at reading mite scrapings. Still, it would be nice if the word got out that diagnosing scabies can be tricky; many other things cause itch at night, and an incorrect designation of scabies can lead to major problems: medical, social, even financial. Physicians unsure of the diagnosis should, at a minimum, advise patients that if two applications of a scabicide haven't made much difference, then what's needed is not a third one, but a new diagnosis.

Mabel, by the way, took a second job as a meter maid to cover her dry cleaning bills and lived happily ever after.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

On the wooden door that leads from my examining room corridor out to the waiting room, a big red sign at eye level reads EXIT. This sign is invisible. Time and again, patients trying to leave walk up to the door, stare at the sign, then turn left, until somebody rescues them and shows them out.

The trouble actually starts sooner. When patients exit the exam room itself, another red sign directly opposite, also at eye level, reads EXIT, with an arrow pointing to the right. This, too, is invisible. At least half of the patients turn left and soon bump into a blank wall, on which I have placed a sign reading, THE WAY OUT IS BEHIND YOU. They ponder this sign—and the blank wall behind it. After a short pause for processing, the message gets through and they turn around.

Few of my patients are blind or illiterate, so why are my signs invisible? The reason is their unfamiliar context. When you don't know where you are, you can hardly see anything. To process data, our senses need the help of background cues.

How much this matters becomes obvious on trips abroad. When people speak to us in a strange language, for instance, we often can't even pick up words we know. Mumbling happens everywhere, but back home we can understand it because we get the rest of the sentence, know what facial expressions and gestures mean, and so forth.

Patients in our offices are travelers in strange lands. We are so at home that it takes effort to realize how lost the patients can get in matters of procedure and etiquette, not to mention medical advice.

Perhaps we and our staffs should think of ourselves as folks who greet tourists at a Visitors Bureau in a country where the people talk funny, act weird, and drive on the wrong side of the road. Here are a few tips:

▸ Checking in. People who are not experienced in HMO-land can be pardoned for assuming that if they call their primary care physician and he or she promises to send a referral, then the doctor has done the job. We know better, of course, but it's fair to be gentle rather than huffy with patients whose referrals have not yet been sent in.

▸ Taking a seat. In each of my exam rooms, in addition to the table, I have a stool and a chair. I sometimes enter to find a patient leaping to her feet and stammering, "Sorry, I'm in your chair!" It helps if the staff member who bring patients into the room tells them where to sit and shows them where to hang clothes. (Door hooks also are invisible.)

▸ Putting on a gown. That you should leave a gown open in back is not self-evident, especially if you're worried about your front. Proper gowning takes both instruction and demonstration. (Even that may not be enough. At my most recent colonoscopy, they told me to put on two johnnies, an upper and a lower—and showed me, too—but I still got them wrong. Both of them.)

▸ Lying down. As everyone knows, if you tell a patient to lie on his back, he will lie on his stomach. If you ask him to lie on his left side, he will turn right.

▸ Knowing what we do for a living. Just because we know what diagnoses we handle and which procedures we perform doesn't mean that our patients know. They ask me things like, "Do you take care of warts?" Even more often, they apologize because their rash got better or their bleeding spot fell off before they came, assuming that anything less than cancer or complete misery is a waste of my time. It doesn't take much effort to assure them otherwise, or to unintentionally embarrass them by acting bored and dismissive.

▸ Going for samples. Unless I tell them emphatically to stay put and that I will be right back, patients who see me leave to get samples are often overcome by fear of abandonment and come running half-clothed into the hall.

▸ Understanding instructions. When do you put the cream on? Must you wait after washing? Do you leave it on, or wash it off? And so on and so forth. Many of these directives, self-evident to us, are anything but that to our visitors.

▸ Exiting. You already know about that.

The bottom line is that when you don't know where you are, almost anything, no matter how simple and obvious, can be inscrutable. Or invisible.

Good morning, Doctor. I went to another dermatology office, but I'm not going back there. Too risky."

"Too risky?"

"They had a staff infection."

"Let's review your history. Do you have any medical issues?"

"Just my prostrate."

"Any skin problems?"

"My mother says when I was an infant I had ectopic dermatitis."

"And after that?"

"As a teenager my face was clear, but I did have bacne."

"Go on."

"In college I got an irritation in my groinal area."

"A fungus?"

"No, but I did have a fungus on my toenails. The test showed a hermaphrodite infection."

"What about the groin rash?"

"I have it on my scalp and elbows too. The doctor said it was seriosis."

"Did he treat you with anything?"

"I got two creams for the elbows, ones that come from farms in warm climates."

"Farms in warm climates?"

"Cultivate and Tropicort."

"Does this rash come on your face?"

"No, but I do have rosetta there."

"Have you had any growths removed?"

"The kind that run in families. Most of my relatives get bumbs."

"Bumbs?"

"Yes, you know. Like skin ticks. The doctor didn't take them off. He had his PI do it."

"Any skin cancers?"

"I did have two plastic nevi removed. And there was a squamish cell on my arm. It just propped up."

"Did the doctor burn it off?"

"No, I was afraid of scarring so he sent me to a surgeon for an exorcision."

"Any other skin problems?"

"I'm a little embarrassed about this. I was once incarcerated, and I got penal warts."

"Were you treated for them while you were in jail?"

"Yes. It was minimum security."

"What else?"

"Gentile herpes."

"Here's a prescription for an antibiotic for your face. What are you looking at?"

"I can't read it. P O … what does POBID mean?"

"Twice a day by mouth. But you don't have to read it. The pharmacist reads it."

"You mean I get this in a pharmacy?"

"Yes."

"Any pharmacy?"

"Yes."

"Can I take it to Drugtown?"

"Any pharmacy."

"How about PHarmaRiot?"

"Yes, there too. What cream did you use for the groin?"

"I knew you'd ask me that, so I wrote it down. Here it is … Fougera!"

"That's the manufacturer."

"It was white. It came in a tube."

"And?"

"It had a yellow stripe. There was a 5 in it. Why am I thinking of Lucy's husband?"

"Desonide?"

"That's it! Say, can't these steroid creams thin your skin?"

"This one is okay."

"Even for the groinal area?"

"Yes. Here's a prescription. Now what are you looking at?"

"It just says BID, but there isn't any PO."

"The technician at PHarmaRiot will type the instructions in English."

"Weren't you going to give me a prescription for the antibiotic for my face, the one with the PO?"

"I did give it to you. You put it away."

"I can't find it. Could you write another one? And I need a different script for a 3-month mail-away."

"Okay, here."

"You wrote only one refill. The mail-away has to have three refills."

"All right."

"I also need a 3-monther for the groinal cream."

"Three refills?"

"Yes. Doc. I have to go."

"How come?"

"Damned prostrate."

Good morning, Doctor. I went to another dermatology office, but I'm not going back there. Too risky."

"Too risky?"

"They had a staff infection."

"Let's review your history. Do you have any medical issues?"

"Just my prostrate."

"Any skin problems?"

"My mother says when I was an infant I had ectopic dermatitis."

"And after that?"

"As a teenager my face was clear, but I did have bacne."

"Go on."

"In college I got an irritation in my groinal area."

"A fungus?"

"No, but I did have a fungus on my toenails. The test showed a hermaphrodite infection."

"What about the groin rash?"

"I have it on my scalp and elbows too. The doctor said it was seriosis."

"Did he treat you with anything?"

"I got two creams for the elbows, ones that come from farms in warm climates."

"Farms in warm climates?"

"Cultivate and Tropicort."

"Does this rash come on your face?"

"No, but I do have rosetta there."

"Have you had any growths removed?"

"The kind that run in families. Most of my relatives get bumbs."

"Bumbs?"

"Yes, you know. Like skin ticks. The doctor didn't take them off. He had his PI do it."

"Any skin cancers?"

"I did have two plastic nevi removed. And there was a squamish cell on my arm. It just propped up."

"Did the doctor burn it off?"

"No, I was afraid of scarring so he sent me to a surgeon for an exorcision."

"Any other skin problems?"

"I'm a little embarrassed about this. I was once incarcerated, and I got penal warts."

"Were you treated for them while you were in jail?"

"Yes. It was minimum security."

"What else?"

"Gentile herpes."

"Here's a prescription for an antibiotic for your face. What are you looking at?"

"I can't read it. P O … what does POBID mean?"

"Twice a day by mouth. But you don't have to read it. The pharmacist reads it."

"You mean I get this in a pharmacy?"

"Yes."

"Any pharmacy?"

"Yes."

"Can I take it to Drugtown?"

"Any pharmacy."

"How about PHarmaRiot?"

"Yes, there too. What cream did you use for the groin?"

"I knew you'd ask me that, so I wrote it down. Here it is … Fougera!"

"That's the manufacturer."

"It was white. It came in a tube."

"And?"

"It had a yellow stripe. There was a 5 in it. Why am I thinking of Lucy's husband?"

"Desonide?"

"That's it! Say, can't these steroid creams thin your skin?"

"This one is okay."

"Even for the groinal area?"

"Yes. Here's a prescription. Now what are you looking at?"

"It just says BID, but there isn't any PO."

"The technician at PHarmaRiot will type the instructions in English."

"Weren't you going to give me a prescription for the antibiotic for my face, the one with the PO?"

"I did give it to you. You put it away."

"I can't find it. Could you write another one? And I need a different script for a 3-month mail-away."

"Okay, here."

"You wrote only one refill. The mail-away has to have three refills."

"All right."

"I also need a 3-monther for the groinal cream."

"Three refills?"

"Yes. Doc. I have to go."

"How come?"

"Damned prostrate."

Good morning, Doctor. I went to another dermatology office, but I'm not going back there. Too risky."

"Too risky?"

"They had a staff infection."

"Let's review your history. Do you have any medical issues?"

"Just my prostrate."

"Any skin problems?"

"My mother says when I was an infant I had ectopic dermatitis."

"And after that?"

"As a teenager my face was clear, but I did have bacne."

"Go on."

"In college I got an irritation in my groinal area."

"A fungus?"

"No, but I did have a fungus on my toenails. The test showed a hermaphrodite infection."

"What about the groin rash?"

"I have it on my scalp and elbows too. The doctor said it was seriosis."

"Did he treat you with anything?"

"I got two creams for the elbows, ones that come from farms in warm climates."

"Farms in warm climates?"

"Cultivate and Tropicort."

"Does this rash come on your face?"

"No, but I do have rosetta there."

"Have you had any growths removed?"

"The kind that run in families. Most of my relatives get bumbs."

"Bumbs?"

"Yes, you know. Like skin ticks. The doctor didn't take them off. He had his PI do it."

"Any skin cancers?"

"I did have two plastic nevi removed. And there was a squamish cell on my arm. It just propped up."

"Did the doctor burn it off?"

"No, I was afraid of scarring so he sent me to a surgeon for an exorcision."

"Any other skin problems?"

"I'm a little embarrassed about this. I was once incarcerated, and I got penal warts."

"Were you treated for them while you were in jail?"

"Yes. It was minimum security."

"What else?"

"Gentile herpes."

"Here's a prescription for an antibiotic for your face. What are you looking at?"

"I can't read it. P O … what does POBID mean?"

"Twice a day by mouth. But you don't have to read it. The pharmacist reads it."

"You mean I get this in a pharmacy?"

"Yes."

"Any pharmacy?"

"Yes."

"Can I take it to Drugtown?"

"Any pharmacy."

"How about PHarmaRiot?"

"Yes, there too. What cream did you use for the groin?"

"I knew you'd ask me that, so I wrote it down. Here it is … Fougera!"

"That's the manufacturer."

"It was white. It came in a tube."

"And?"

"It had a yellow stripe. There was a 5 in it. Why am I thinking of Lucy's husband?"

"Desonide?"

"That's it! Say, can't these steroid creams thin your skin?"

"This one is okay."

"Even for the groinal area?"

"Yes. Here's a prescription. Now what are you looking at?"

"It just says BID, but there isn't any PO."

"The technician at PHarmaRiot will type the instructions in English."

"Weren't you going to give me a prescription for the antibiotic for my face, the one with the PO?"

"I did give it to you. You put it away."

"I can't find it. Could you write another one? And I need a different script for a 3-month mail-away."

"Okay, here."

"You wrote only one refill. The mail-away has to have three refills."

"All right."

"I also need a 3-monther for the groinal cream."

"Three refills?"

"Yes. Doc. I have to go."

"How come?"

"Damned prostrate."

They removed a mole when I was 17," Claire said, pointing to her knee. The scar had faded to white in the 50 years since.

Claire had come for a body check. Her special concerns were the seborrheic keratoses on her torso. "Do you think," she asked, eyeing them suspiciously, "these spots coming out are from the mole they took off my knee?"

Clinical work involves a bit of ethnography. Understanding other cultures with alien ideas can be hard; it's even harder when the people from the other culture look just like you.

Claire is a retired teacher from a Boston suburb. You would never guess from her dress and demeanor that her concept of the body has little in common with the one they teach in medical school.

The key to understanding Claire lies in the homely word "roots."

Our patients apply it to the common skin growths we treat every day, as in, "Don't these warts have roots, Doctor?"

That sort of question might not matter to us, perhaps, but to some patients it matters a great deal. A 27-year-old woman, a graduate student in physiology of all things, once asked me, "Isn't it true that plantar warts can grow deep, into the bone?"

That it's not true doesn't stop her—and many others—from wondering. Patients distinguish between wart types. ("These warts on my hands look like 'Planter's warts.'") The salient characteristic of Planter's warts is not their plantar location but their presumed roots.

Or consider nevi. It's not uncommon for patients to ask, "Don't these moles have root systems under the skin, like a tree?" One patient used a different analogy. "I understand," he said as he pointed to a dermal nevus on his hip, "that a mole is like an inverted golf tee. Most of it is deep underneath."

It would be a mistake to think that such people are uniquely imaginative or deluded. Their ideas are not universal, but they're out there. What they imply is that the medical conception of the body, assumed to be held by every modern and educated person, in fact lives alongside a very different one, an older concept that supposedly went away but didn't.

To doctors, the body has a skin on the outside; inside are many organs—stomach, liver, coiled intestines, and so forth. To many of our patients, however, the Inside is something dark and undifferentiated. Bad things come out of it that would poison the body if not gotten rid of: urine, feces, sweat, sebum.

Diseases come out of the inside too, as "eruptions" or "breakouts," on the skin. Surface rashes are really "systemic." Before you dismiss these as archaic metaphors, listen as patients call warts on the hands, "a virus in my body."

Patients conceive our innards less like a Frank Netter illustration and more like a gloomy cavern, complete with cobwebs and bats. Below, a boiling lake expels excretions and emits eruptions that waft up and out. Above, ugly branching tendrils criss-cross up to their points of attachment on the roof and walls—these are the "roots" of what is poking out above.

This may sound fanciful, but don't take my word for it. Next time you remove a keratosis, wart, or mole, try telling:

▸ The woman whose irritated SK you're curetting, "These keratoses are just stuck onto the top of the skin. They don't have any roots."

▸ The man whose mole you're shaving, "Moles don't have roots, of course."

▸ The mother of a child with plantar warts, "You might be interested to know that plantar warts are thick, but they're just in the epidermis. They don't have roots."

See how often your statement elicits a look of relief—and revelation. For 50 years, Claire's been waiting for the roots of her mole to pop up somewhere else, so naturally her sprouting keratoses seemed to her to be the Mole's Revenge.

Exploring roots can bring unexpected rewards. Give it a try.

They removed a mole when I was 17," Claire said, pointing to her knee. The scar had faded to white in the 50 years since.

Claire had come for a body check. Her special concerns were the seborrheic keratoses on her torso. "Do you think," she asked, eyeing them suspiciously, "these spots coming out are from the mole they took off my knee?"

Clinical work involves a bit of ethnography. Understanding other cultures with alien ideas can be hard; it's even harder when the people from the other culture look just like you.

Claire is a retired teacher from a Boston suburb. You would never guess from her dress and demeanor that her concept of the body has little in common with the one they teach in medical school.

The key to understanding Claire lies in the homely word "roots."

Our patients apply it to the common skin growths we treat every day, as in, "Don't these warts have roots, Doctor?"

That sort of question might not matter to us, perhaps, but to some patients it matters a great deal. A 27-year-old woman, a graduate student in physiology of all things, once asked me, "Isn't it true that plantar warts can grow deep, into the bone?"

That it's not true doesn't stop her—and many others—from wondering. Patients distinguish between wart types. ("These warts on my hands look like 'Planter's warts.'") The salient characteristic of Planter's warts is not their plantar location but their presumed roots.

Or consider nevi. It's not uncommon for patients to ask, "Don't these moles have root systems under the skin, like a tree?" One patient used a different analogy. "I understand," he said as he pointed to a dermal nevus on his hip, "that a mole is like an inverted golf tee. Most of it is deep underneath."

It would be a mistake to think that such people are uniquely imaginative or deluded. Their ideas are not universal, but they're out there. What they imply is that the medical conception of the body, assumed to be held by every modern and educated person, in fact lives alongside a very different one, an older concept that supposedly went away but didn't.

To doctors, the body has a skin on the outside; inside are many organs—stomach, liver, coiled intestines, and so forth. To many of our patients, however, the Inside is something dark and undifferentiated. Bad things come out of it that would poison the body if not gotten rid of: urine, feces, sweat, sebum.

Diseases come out of the inside too, as "eruptions" or "breakouts," on the skin. Surface rashes are really "systemic." Before you dismiss these as archaic metaphors, listen as patients call warts on the hands, "a virus in my body."

Patients conceive our innards less like a Frank Netter illustration and more like a gloomy cavern, complete with cobwebs and bats. Below, a boiling lake expels excretions and emits eruptions that waft up and out. Above, ugly branching tendrils criss-cross up to their points of attachment on the roof and walls—these are the "roots" of what is poking out above.

This may sound fanciful, but don't take my word for it. Next time you remove a keratosis, wart, or mole, try telling:

▸ The woman whose irritated SK you're curetting, "These keratoses are just stuck onto the top of the skin. They don't have any roots."

▸ The man whose mole you're shaving, "Moles don't have roots, of course."

▸ The mother of a child with plantar warts, "You might be interested to know that plantar warts are thick, but they're just in the epidermis. They don't have roots."

See how often your statement elicits a look of relief—and revelation. For 50 years, Claire's been waiting for the roots of her mole to pop up somewhere else, so naturally her sprouting keratoses seemed to her to be the Mole's Revenge.

Exploring roots can bring unexpected rewards. Give it a try.

They removed a mole when I was 17," Claire said, pointing to her knee. The scar had faded to white in the 50 years since.

Claire had come for a body check. Her special concerns were the seborrheic keratoses on her torso. "Do you think," she asked, eyeing them suspiciously, "these spots coming out are from the mole they took off my knee?"

Clinical work involves a bit of ethnography. Understanding other cultures with alien ideas can be hard; it's even harder when the people from the other culture look just like you.

Claire is a retired teacher from a Boston suburb. You would never guess from her dress and demeanor that her concept of the body has little in common with the one they teach in medical school.

The key to understanding Claire lies in the homely word "roots."

Our patients apply it to the common skin growths we treat every day, as in, "Don't these warts have roots, Doctor?"

That sort of question might not matter to us, perhaps, but to some patients it matters a great deal. A 27-year-old woman, a graduate student in physiology of all things, once asked me, "Isn't it true that plantar warts can grow deep, into the bone?"

That it's not true doesn't stop her—and many others—from wondering. Patients distinguish between wart types. ("These warts on my hands look like 'Planter's warts.'") The salient characteristic of Planter's warts is not their plantar location but their presumed roots.

Or consider nevi. It's not uncommon for patients to ask, "Don't these moles have root systems under the skin, like a tree?" One patient used a different analogy. "I understand," he said as he pointed to a dermal nevus on his hip, "that a mole is like an inverted golf tee. Most of it is deep underneath."

It would be a mistake to think that such people are uniquely imaginative or deluded. Their ideas are not universal, but they're out there. What they imply is that the medical conception of the body, assumed to be held by every modern and educated person, in fact lives alongside a very different one, an older concept that supposedly went away but didn't.

To doctors, the body has a skin on the outside; inside are many organs—stomach, liver, coiled intestines, and so forth. To many of our patients, however, the Inside is something dark and undifferentiated. Bad things come out of it that would poison the body if not gotten rid of: urine, feces, sweat, sebum.

Diseases come out of the inside too, as "eruptions" or "breakouts," on the skin. Surface rashes are really "systemic." Before you dismiss these as archaic metaphors, listen as patients call warts on the hands, "a virus in my body."

Patients conceive our innards less like a Frank Netter illustration and more like a gloomy cavern, complete with cobwebs and bats. Below, a boiling lake expels excretions and emits eruptions that waft up and out. Above, ugly branching tendrils criss-cross up to their points of attachment on the roof and walls—these are the "roots" of what is poking out above.

This may sound fanciful, but don't take my word for it. Next time you remove a keratosis, wart, or mole, try telling:

▸ The woman whose irritated SK you're curetting, "These keratoses are just stuck onto the top of the skin. They don't have any roots."

▸ The man whose mole you're shaving, "Moles don't have roots, of course."

▸ The mother of a child with plantar warts, "You might be interested to know that plantar warts are thick, but they're just in the epidermis. They don't have roots."

See how often your statement elicits a look of relief—and revelation. For 50 years, Claire's been waiting for the roots of her mole to pop up somewhere else, so naturally her sprouting keratoses seemed to her to be the Mole's Revenge.

Exploring roots can bring unexpected rewards. Give it a try.

A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.

Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.

The pathologist called, sounding perplexed. "Was he … around any cacti?"

Drat! I always forget to ask patients whether they've cuddled any cacti.

When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…

Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.

In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.

Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.

Here are a few examples from my own collection:

▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.

Hot-tub folliculitis? No whirlpool baths in the park.

Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?

I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.

▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.

A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.

It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.

Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.

Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.

He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.

▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.

"Have you," I ask, looking mysterious, "had any margaritas lately?"

"Why, yes!" they reply, startled. "In Cancun."

"Where you had your drink in a lounge chair, right?"

They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.

▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.

Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.

Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.

Other vacationers show up with cnidarian tales.

Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.

What counts as exotic depends, of course, on where you live.

Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.

"Do you think we'll get to see poison ivy?" she asked.

I told her we might indeed.

A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.

Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.

The pathologist called, sounding perplexed. "Was he … around any cacti?"

Drat! I always forget to ask patients whether they've cuddled any cacti.

When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…

Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.

In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.

Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.

Here are a few examples from my own collection:

▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.

Hot-tub folliculitis? No whirlpool baths in the park.

Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?

I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.

▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.

A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.

It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.

Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.

Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.

He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.

▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.

"Have you," I ask, looking mysterious, "had any margaritas lately?"

"Why, yes!" they reply, startled. "In Cancun."

"Where you had your drink in a lounge chair, right?"

They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.

▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.

Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.

Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.

Other vacationers show up with cnidarian tales.

Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.

What counts as exotic depends, of course, on where you live.

Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.

"Do you think we'll get to see poison ivy?" she asked.

I told her we might indeed.

A doctor asked me to see his nephew from Albuquerque who was enrolled at a nearby college. He told me the young man had just come back from semester break with a rash.

Indeed he had: juicy purple nodules all over his torso. Lymphoma? With foreboding, I biopsied.

The pathologist called, sounding perplexed. "Was he … around any cacti?"

Drat! I always forget to ask patients whether they've cuddled any cacti.

When I asked the student, he replied, "I did go camping in the desert with my girlfriend." Not just your girlfriend, sonny.…

Here in the Northeast, cactus granulomas are exotic, a diagnostic coup worth sharing with colleagues.

In New Mexico I'll bet every dermatologist and family physician—not to mention Eagle Scout—could probably diagnose them in a flash.

Regional diseases, trivial to locals, can pose challenges to recognition when they show up elsewhere.

Here are a few examples from my own collection:

▸ Private bites. The medical couple had returned from an Alabama conference with the worst itch they could remember. After the lectures, the pair had camped overnight in a field. They showed me red papules concentrated in their midriff and groin areas.

Hot-tub folliculitis? No whirlpool baths in the park.

Bites? We see plenty of those around here—greenhead bites in the summer are especially impressive—but why would bites be limited to covered areas?

I looked in some texts and learned that chigger mites cause particularly intense itch and do their best work under elastic. Southern and midwestern practitioners would probably surmise the diagnosis over the phone.

▸ Talking to the trees. Eric came back from building homes for the poor in Honduras with great memories and a nasty rash.

A local dermatologist had given him pills. What doctor? Which pills? Eric could remember only something about a tree called "palo brujo." He said that locals who got the rash talked to the tree to get better, but Eric could speak neither Spanish nor tree.

It was fortunate that Roberto, the medical student with me that month, hailed from Mexico City.

Applying both linguistic and technical savvy, which included "Googling" in Spanish, he found that the botanical name of the tree known popularly as palo de brujo is Vochysia hondurensis, but I couldn't find that in any of the contact dermatitis texts.

Using clues from Eric, Roberto tracked down the Honduran dermatologist; his clinic receptionist said he wasn't in but gave us his mobile (!) phone number. Because cellular connectivity in Tegucigalpa appears to be superior to that in Brookline, Mass., we reached him at once with a crisp connection.

He could not have been more cordial, explaining that contact dermatitis to this tree was common and responded to the same tapering prednisone regimen we use up here for acute contact dermatitis. Eric is fine, and now we all know a bit more about the flora and folk practices of Central America than we used to.

▸ Barkeep—get me a rash. I love it when college students show up, usually in January or April, with a macular rash that looks as though something dripped down their thighs and left a dark brown trail.

"Have you," I ask, looking mysterious, "had any margaritas lately?"

"Why, yes!" they reply, startled. "In Cancun."

"Where you had your drink in a lounge chair, right?"

They shouldn't be impressed. I'm told that in Cancun the bartenders can diagnose phytophotodermatitis.

▸ Louse ahoy! The first time a patient came back from Florida claiming to have been bitten by sea lice, I pictured a pediculosis convention at the Fontainebleau.

Later I learned what most every southeast Floridian—dermatologist or otherwise—presumably knows: "Sea lice" is a misnomer for seabather's eruption, caused by larvae of cnidarians such as jellyfish and anemones.

Supposedly this can occur on Cape Cod, but the water temperature up here discourages seabathers from actually bathing in the sea.

Other vacationers show up with cnidarian tales.

Not long ago one described swimming through a phalanx of dead jellyfish in a scene reminiscent of the one in "Finding Nemo," but without the happy ending. Stuff like that never makes the travel brochures.

What counts as exotic depends, of course, on where you live.

Last year a student from Nebraska scheduled an elective in Boston because she wanted to see rare and unusual cases.

"Do you think we'll get to see poison ivy?" she asked.

I told her we might indeed.