Under My Skin

People like to quote George Santayana, who said that those who forget history are doomed to repeat it. Few realize he was referring to the treatment of cutaneous fungal infections.

OK, he wasn't exactly referring to ringworm, but he could have been.

In complex matters like politics and human relations, history is hard to learn from because no two situations are exactly the same.

Scaly skin rashes, however, are not complicated at all. There are only a few possibilities, the most common of which are fungus and eczema. Two simple tests can distinguish them: a potassium hydroxide (KOH) prep and a culture. Even without testing, simple observation of clinical response should do the trick. A steroid cream makes a fungus worse and eczema better; an antifungal cream makes fungus better and does little or nothing for eczema.

Yet generations of nondermatologists continue to treat inflammatory rashes—nummular eczema, balanitis, submammary intertrigo, and so forth—with antifungal creams. My question is not how they can make that mistake; anyone can make a mistake. My question is why they keep making it. Why do so many experienced clinicians, decade after decade, never seem to get any better at making this straightforward, clear-cut distinction?

A close analysis is needed. The mechanism for perpetuating this simple mistake may shed light on the persistence of errors of greater consequence. I will map the intellectual progress of a doctor I'll call XY, to avoid gender bias. There are four steps:

1. Childhood training. Along with everyone else, XY learns early that skin diseases are connected with dirt. The germs presumed to cause rashes are dirty too, especially fungi. Tell Jane she has eczema and she protests, "But I shower every day!" Joey can't fathom why he breaks out—he washes so often. And of course everybody wears flip-flops in the locker room, since we all know what you catch there.

2. (Non)education. In medical school, XY learns nothing about managing ordinary skin problems. The occasional slide presentation may provide passing mastery of discoid lupus or acanthosis nigricans, conditions of interest to the presenter. XY departs medical school with the same assumptions about the rash-dirt nexus with which he or she entered.

3. Pavlovian reinforcement. When XY encounters skin problems during residency, the rash is always incidental to the patient's true problem: heart disease, cancer, and other illnesses of real importance. If the skin issue is noted at all, senior staff will instruct XY that it is probably fungal and treat accordingly. Should XY have the temerity to suggest otherwise and propose treatment with a topical steroid, faculty will exclaim, "Steroids weaken the immune system—you can't put them on an infection!" XY won't make that mistake again.

4. Indifference. Clinical practice will provide XY with few stimuli to unlearn default fungal assumption. When the disease at hand is actually fungal, antifungal creams make the patients better. More often, such creams are irrelevant except as emollients, but the patients don't call to complain. Perhaps the rash never bothered them that much, or the eczema remitted on its own. XY therefore never discovers the error. More severe rashes may generate a dermatologic consultation. The dermatologist's referral letter is read with little interest, if any. XY expects no collegial pats on the back for getting rashes right, fears no lawsuit or public ridicule at grand rounds for getting them wrong.

The mistake therefore does not correct itself, and life goes on.

Santayana notwithstanding, history lessons are hard to learn. When matters are complex, its lessons may be nuanced and ambiguous. What history teaches may be hard to understand or painful to accept.

Then again we may not learn because of simple indifference; we just aren't motivated to bother. Glory and shame are good motivators. Professional integrity and intellectual curiosity should work too, but the evidence suggests they often don't. XY is not interested in learning the distinction between fungus and eczema, XY's educators are not interested in teaching it, and XY's patients aren't bothered enough by the problem to bring the issue to a head.

We all make mistakes. Scaly skin rashes are just an example of the process by which we can go on making the same ones. It might be useful now and then to stop and investigate how many errors we make every day because we can't be bothered to find out that we made them.

People like to quote George Santayana, who said that those who forget history are doomed to repeat it. Few realize he was referring to the treatment of cutaneous fungal infections.

OK, he wasn't exactly referring to ringworm, but he could have been.

In complex matters like politics and human relations, history is hard to learn from because no two situations are exactly the same.

Scaly skin rashes, however, are not complicated at all. There are only a few possibilities, the most common of which are fungus and eczema. Two simple tests can distinguish them: a potassium hydroxide (KOH) prep and a culture. Even without testing, simple observation of clinical response should do the trick. A steroid cream makes a fungus worse and eczema better; an antifungal cream makes fungus better and does little or nothing for eczema.

Yet generations of nondermatologists continue to treat inflammatory rashes—nummular eczema, balanitis, submammary intertrigo, and so forth—with antifungal creams. My question is not how they can make that mistake; anyone can make a mistake. My question is why they keep making it. Why do so many experienced clinicians, decade after decade, never seem to get any better at making this straightforward, clear-cut distinction?

A close analysis is needed. The mechanism for perpetuating this simple mistake may shed light on the persistence of errors of greater consequence. I will map the intellectual progress of a doctor I'll call XY, to avoid gender bias. There are four steps:

1. Childhood training. Along with everyone else, XY learns early that skin diseases are connected with dirt. The germs presumed to cause rashes are dirty too, especially fungi. Tell Jane she has eczema and she protests, "But I shower every day!" Joey can't fathom why he breaks out—he washes so often. And of course everybody wears flip-flops in the locker room, since we all know what you catch there.

2. (Non)education. In medical school, XY learns nothing about managing ordinary skin problems. The occasional slide presentation may provide passing mastery of discoid lupus or acanthosis nigricans, conditions of interest to the presenter. XY departs medical school with the same assumptions about the rash-dirt nexus with which he or she entered.

3. Pavlovian reinforcement. When XY encounters skin problems during residency, the rash is always incidental to the patient's true problem: heart disease, cancer, and other illnesses of real importance. If the skin issue is noted at all, senior staff will instruct XY that it is probably fungal and treat accordingly. Should XY have the temerity to suggest otherwise and propose treatment with a topical steroid, faculty will exclaim, "Steroids weaken the immune system—you can't put them on an infection!" XY won't make that mistake again.

4. Indifference. Clinical practice will provide XY with few stimuli to unlearn default fungal assumption. When the disease at hand is actually fungal, antifungal creams make the patients better. More often, such creams are irrelevant except as emollients, but the patients don't call to complain. Perhaps the rash never bothered them that much, or the eczema remitted on its own. XY therefore never discovers the error. More severe rashes may generate a dermatologic consultation. The dermatologist's referral letter is read with little interest, if any. XY expects no collegial pats on the back for getting rashes right, fears no lawsuit or public ridicule at grand rounds for getting them wrong.

The mistake therefore does not correct itself, and life goes on.

Santayana notwithstanding, history lessons are hard to learn. When matters are complex, its lessons may be nuanced and ambiguous. What history teaches may be hard to understand or painful to accept.

Then again we may not learn because of simple indifference; we just aren't motivated to bother. Glory and shame are good motivators. Professional integrity and intellectual curiosity should work too, but the evidence suggests they often don't. XY is not interested in learning the distinction between fungus and eczema, XY's educators are not interested in teaching it, and XY's patients aren't bothered enough by the problem to bring the issue to a head.

We all make mistakes. Scaly skin rashes are just an example of the process by which we can go on making the same ones. It might be useful now and then to stop and investigate how many errors we make every day because we can't be bothered to find out that we made them.

People like to quote George Santayana, who said that those who forget history are doomed to repeat it. Few realize he was referring to the treatment of cutaneous fungal infections.

OK, he wasn't exactly referring to ringworm, but he could have been.

In complex matters like politics and human relations, history is hard to learn from because no two situations are exactly the same.

Scaly skin rashes, however, are not complicated at all. There are only a few possibilities, the most common of which are fungus and eczema. Two simple tests can distinguish them: a potassium hydroxide (KOH) prep and a culture. Even without testing, simple observation of clinical response should do the trick. A steroid cream makes a fungus worse and eczema better; an antifungal cream makes fungus better and does little or nothing for eczema.

Yet generations of nondermatologists continue to treat inflammatory rashes—nummular eczema, balanitis, submammary intertrigo, and so forth—with antifungal creams. My question is not how they can make that mistake; anyone can make a mistake. My question is why they keep making it. Why do so many experienced clinicians, decade after decade, never seem to get any better at making this straightforward, clear-cut distinction?

A close analysis is needed. The mechanism for perpetuating this simple mistake may shed light on the persistence of errors of greater consequence. I will map the intellectual progress of a doctor I'll call XY, to avoid gender bias. There are four steps:

1. Childhood training. Along with everyone else, XY learns early that skin diseases are connected with dirt. The germs presumed to cause rashes are dirty too, especially fungi. Tell Jane she has eczema and she protests, "But I shower every day!" Joey can't fathom why he breaks out—he washes so often. And of course everybody wears flip-flops in the locker room, since we all know what you catch there.

2. (Non)education. In medical school, XY learns nothing about managing ordinary skin problems. The occasional slide presentation may provide passing mastery of discoid lupus or acanthosis nigricans, conditions of interest to the presenter. XY departs medical school with the same assumptions about the rash-dirt nexus with which he or she entered.

3. Pavlovian reinforcement. When XY encounters skin problems during residency, the rash is always incidental to the patient's true problem: heart disease, cancer, and other illnesses of real importance. If the skin issue is noted at all, senior staff will instruct XY that it is probably fungal and treat accordingly. Should XY have the temerity to suggest otherwise and propose treatment with a topical steroid, faculty will exclaim, "Steroids weaken the immune system—you can't put them on an infection!" XY won't make that mistake again.

4. Indifference. Clinical practice will provide XY with few stimuli to unlearn default fungal assumption. When the disease at hand is actually fungal, antifungal creams make the patients better. More often, such creams are irrelevant except as emollients, but the patients don't call to complain. Perhaps the rash never bothered them that much, or the eczema remitted on its own. XY therefore never discovers the error. More severe rashes may generate a dermatologic consultation. The dermatologist's referral letter is read with little interest, if any. XY expects no collegial pats on the back for getting rashes right, fears no lawsuit or public ridicule at grand rounds for getting them wrong.

The mistake therefore does not correct itself, and life goes on.

Santayana notwithstanding, history lessons are hard to learn. When matters are complex, its lessons may be nuanced and ambiguous. What history teaches may be hard to understand or painful to accept.

Then again we may not learn because of simple indifference; we just aren't motivated to bother. Glory and shame are good motivators. Professional integrity and intellectual curiosity should work too, but the evidence suggests they often don't. XY is not interested in learning the distinction between fungus and eczema, XY's educators are not interested in teaching it, and XY's patients aren't bothered enough by the problem to bring the issue to a head.

We all make mistakes. Scaly skin rashes are just an example of the process by which we can go on making the same ones. It might be useful now and then to stop and investigate how many errors we make every day because we can't be bothered to find out that we made them.

Dear Children,

You adorable little tykes sure don't hold things back the way we grownups do (sometimes). If you think it, you say it.

That's why I'm so grateful to you for asking your Mom, "What are those ugly brown spots on your hands?" Or telling Dad to stop scratching and making fun of him for being so pale. Or letting Grandma know how much you hate those hanging things on her neck.

Your teacher, Ms. Beecher, has been on medical leave for a month. She sits at her mirror and picks at her acne just thinking about what you'd say if you saw her.

George Washington said that honesty is the best policy. Your honesty really works for me.

Thanks!

Dear Infant,

Besides the producers of Teletubbies, no one gives you the credit you deserve for noticing things.

I appreciate you, though. Like when your Mom comes in to have me remove a mole on her chest because you grab at it while you're nursing. Or when you're a little older and point to some mark and yell, "Boo boo!"

You hate bumps, you little devil, don't you? They violate your cute baby sense of order and regularity. When you grow up, you and your health insurer will have fun arguing the exact meaning of "cosmetic" and listing reasons that make it OK for you to get rid of the bumps you've been pointing and grabbing at forever.

Send me those boo-boos!

Goo.

Dear Manicurist/Pedicurist,

I don't know how to thank you for your ongoing project of calling everything you see a fungus. People think that anyway—it really grosses them out—but hearing your expert opinion clinches things. Plus, when you jab at their cuticles, they worry that you're not just diagnosing disease, but causing it.

Of course, I sometimes have trouble talking them out of demanding fungus pills that won't help, but at least they come to the office.

Remember—every nail discoloration or irregularity is a fungus. But you knew that.

Ciao.

Dear Internet,

Web, you really rock!

It used to be that self-diagnosers had to go to a bookstore or library and lug home heavy symptom books, risking back strain or hernia. Now a few mouse clicks in the comfort of their own den, and there's no disease on Earth they can't learn about, see pictures of, and share neuroses and therapeutic advice with sufferers from.

A spot on the groin? Herpes! Fever and a rash? AIDS! Dry lips? Chapstick addiction! A sore belly? Kala-azar! Without you, patients would never even hear about a 10th of the things they now worry about in encyclopedic detail.

Talking them out of these diagnoses and therapies can be tricky. Yet who can argue with the merits of Jeri-Gel for striae and Sculpt-a-Butt for cellulite, with their unconditional, money-back guarantees? Or with green tea compresses and decoctions for everything from asthma to wrinkles to periodontal disease? Or with a 30-page chat-room string on Grover's disease, touting everything from prednisone to Solaraze?

So whether you're academic and ponderous, lay oriented and flip, or just the cyberequivalent of a nosy neighbor, thanks for your support!

Dear Mammography Technician,

I don't know whether seborrheic keratoses really do cast shadows on mammograms, but your concern over them in the mammography field sure generates a lot of referrals. Women are anxious about their breasts anyway, so telling them, "You'd better get that off!" is a great help.

Thanks.

Dear Camera,

Whoever asked for the power to see ourselves as others see us must have had you in mind. Seeing your mug in a photo, or even worse, on camera, has an effect similar to hearing your voice on a tape recording—an acute wish to hide under a rock. With pictures, however, the discomfort is more specific: "Good grief—how long have I had that thing on my cheek?!"

Thanks for the referrals.

Dear Physician,

I sometimes write you in my capacity of consulting colleague, even though the tenor of your referral is often on the order of, "Madge at the front desk has the names of a coupla skin guys. Whyncha pick one?"

At other times, though, the patient comes not because you sent her, but because you walked into the exam room and exclaimed, "WHAT THE DICKENS IS THAT??!!" I've heard too many such tales to dismiss them as poor reporting.

There seems to be something about skin disease that induces exclamations of visceral alarm that go beyond mere perplexity. Other diseases may be pretty inscrutable, yet I can't imagine a doctor looking at a lab report and crying, "Omigosh—your kidneys are a wreck! Check with Madge—she has a list of nephro guys."

Although it might be more professional if you deleted those expletives, I do appreciate your sending folks over.

Sincere thanks to all of you,

A. Derm, M.D.

Dear Children,

You adorable little tykes sure don't hold things back the way we grownups do (sometimes). If you think it, you say it.

That's why I'm so grateful to you for asking your Mom, "What are those ugly brown spots on your hands?" Or telling Dad to stop scratching and making fun of him for being so pale. Or letting Grandma know how much you hate those hanging things on her neck.

Your teacher, Ms. Beecher, has been on medical leave for a month. She sits at her mirror and picks at her acne just thinking about what you'd say if you saw her.

George Washington said that honesty is the best policy. Your honesty really works for me.

Thanks!

Dear Infant,

Besides the producers of Teletubbies, no one gives you the credit you deserve for noticing things.

I appreciate you, though. Like when your Mom comes in to have me remove a mole on her chest because you grab at it while you're nursing. Or when you're a little older and point to some mark and yell, "Boo boo!"

You hate bumps, you little devil, don't you? They violate your cute baby sense of order and regularity. When you grow up, you and your health insurer will have fun arguing the exact meaning of "cosmetic" and listing reasons that make it OK for you to get rid of the bumps you've been pointing and grabbing at forever.

Send me those boo-boos!

Goo.

Dear Manicurist/Pedicurist,

I don't know how to thank you for your ongoing project of calling everything you see a fungus. People think that anyway—it really grosses them out—but hearing your expert opinion clinches things. Plus, when you jab at their cuticles, they worry that you're not just diagnosing disease, but causing it.

Of course, I sometimes have trouble talking them out of demanding fungus pills that won't help, but at least they come to the office.

Remember—every nail discoloration or irregularity is a fungus. But you knew that.

Ciao.

Dear Internet,

Web, you really rock!

It used to be that self-diagnosers had to go to a bookstore or library and lug home heavy symptom books, risking back strain or hernia. Now a few mouse clicks in the comfort of their own den, and there's no disease on Earth they can't learn about, see pictures of, and share neuroses and therapeutic advice with sufferers from.

A spot on the groin? Herpes! Fever and a rash? AIDS! Dry lips? Chapstick addiction! A sore belly? Kala-azar! Without you, patients would never even hear about a 10th of the things they now worry about in encyclopedic detail.

Talking them out of these diagnoses and therapies can be tricky. Yet who can argue with the merits of Jeri-Gel for striae and Sculpt-a-Butt for cellulite, with their unconditional, money-back guarantees? Or with green tea compresses and decoctions for everything from asthma to wrinkles to periodontal disease? Or with a 30-page chat-room string on Grover's disease, touting everything from prednisone to Solaraze?

So whether you're academic and ponderous, lay oriented and flip, or just the cyberequivalent of a nosy neighbor, thanks for your support!

Dear Mammography Technician,

I don't know whether seborrheic keratoses really do cast shadows on mammograms, but your concern over them in the mammography field sure generates a lot of referrals. Women are anxious about their breasts anyway, so telling them, "You'd better get that off!" is a great help.

Thanks.

Dear Camera,

Whoever asked for the power to see ourselves as others see us must have had you in mind. Seeing your mug in a photo, or even worse, on camera, has an effect similar to hearing your voice on a tape recording—an acute wish to hide under a rock. With pictures, however, the discomfort is more specific: "Good grief—how long have I had that thing on my cheek?!"

Thanks for the referrals.

Dear Physician,

I sometimes write you in my capacity of consulting colleague, even though the tenor of your referral is often on the order of, "Madge at the front desk has the names of a coupla skin guys. Whyncha pick one?"

At other times, though, the patient comes not because you sent her, but because you walked into the exam room and exclaimed, "WHAT THE DICKENS IS THAT??!!" I've heard too many such tales to dismiss them as poor reporting.

There seems to be something about skin disease that induces exclamations of visceral alarm that go beyond mere perplexity. Other diseases may be pretty inscrutable, yet I can't imagine a doctor looking at a lab report and crying, "Omigosh—your kidneys are a wreck! Check with Madge—she has a list of nephro guys."

Although it might be more professional if you deleted those expletives, I do appreciate your sending folks over.

Sincere thanks to all of you,

A. Derm, M.D.

Dear Children,

You adorable little tykes sure don't hold things back the way we grownups do (sometimes). If you think it, you say it.

That's why I'm so grateful to you for asking your Mom, "What are those ugly brown spots on your hands?" Or telling Dad to stop scratching and making fun of him for being so pale. Or letting Grandma know how much you hate those hanging things on her neck.

Your teacher, Ms. Beecher, has been on medical leave for a month. She sits at her mirror and picks at her acne just thinking about what you'd say if you saw her.

George Washington said that honesty is the best policy. Your honesty really works for me.

Thanks!

Dear Infant,

Besides the producers of Teletubbies, no one gives you the credit you deserve for noticing things.

I appreciate you, though. Like when your Mom comes in to have me remove a mole on her chest because you grab at it while you're nursing. Or when you're a little older and point to some mark and yell, "Boo boo!"

You hate bumps, you little devil, don't you? They violate your cute baby sense of order and regularity. When you grow up, you and your health insurer will have fun arguing the exact meaning of "cosmetic" and listing reasons that make it OK for you to get rid of the bumps you've been pointing and grabbing at forever.

Send me those boo-boos!

Goo.

Dear Manicurist/Pedicurist,

I don't know how to thank you for your ongoing project of calling everything you see a fungus. People think that anyway—it really grosses them out—but hearing your expert opinion clinches things. Plus, when you jab at their cuticles, they worry that you're not just diagnosing disease, but causing it.

Of course, I sometimes have trouble talking them out of demanding fungus pills that won't help, but at least they come to the office.

Remember—every nail discoloration or irregularity is a fungus. But you knew that.

Ciao.

Dear Internet,

Web, you really rock!

It used to be that self-diagnosers had to go to a bookstore or library and lug home heavy symptom books, risking back strain or hernia. Now a few mouse clicks in the comfort of their own den, and there's no disease on Earth they can't learn about, see pictures of, and share neuroses and therapeutic advice with sufferers from.

A spot on the groin? Herpes! Fever and a rash? AIDS! Dry lips? Chapstick addiction! A sore belly? Kala-azar! Without you, patients would never even hear about a 10th of the things they now worry about in encyclopedic detail.

Talking them out of these diagnoses and therapies can be tricky. Yet who can argue with the merits of Jeri-Gel for striae and Sculpt-a-Butt for cellulite, with their unconditional, money-back guarantees? Or with green tea compresses and decoctions for everything from asthma to wrinkles to periodontal disease? Or with a 30-page chat-room string on Grover's disease, touting everything from prednisone to Solaraze?

So whether you're academic and ponderous, lay oriented and flip, or just the cyberequivalent of a nosy neighbor, thanks for your support!

Dear Mammography Technician,

I don't know whether seborrheic keratoses really do cast shadows on mammograms, but your concern over them in the mammography field sure generates a lot of referrals. Women are anxious about their breasts anyway, so telling them, "You'd better get that off!" is a great help.

Thanks.

Dear Camera,

Whoever asked for the power to see ourselves as others see us must have had you in mind. Seeing your mug in a photo, or even worse, on camera, has an effect similar to hearing your voice on a tape recording—an acute wish to hide under a rock. With pictures, however, the discomfort is more specific: "Good grief—how long have I had that thing on my cheek?!"

Thanks for the referrals.

Dear Physician,

I sometimes write you in my capacity of consulting colleague, even though the tenor of your referral is often on the order of, "Madge at the front desk has the names of a coupla skin guys. Whyncha pick one?"

At other times, though, the patient comes not because you sent her, but because you walked into the exam room and exclaimed, "WHAT THE DICKENS IS THAT??!!" I've heard too many such tales to dismiss them as poor reporting.

There seems to be something about skin disease that induces exclamations of visceral alarm that go beyond mere perplexity. Other diseases may be pretty inscrutable, yet I can't imagine a doctor looking at a lab report and crying, "Omigosh—your kidneys are a wreck! Check with Madge—she has a list of nephro guys."

Although it might be more professional if you deleted those expletives, I do appreciate your sending folks over.

Sincere thanks to all of you,

A. Derm, M.D.

If you ask patients not just why they came but why they came now, you'll often find that a third party was involved. Whatever is wrong may have been there for some time, raising no concern in the patient's mind until someone else stared at it and warned, "You'd better get that taken care of!"

Now and then this is a colleague. In that case, I can write a letter acknowledging the referral:

Dear Chip,

Thanks so much for referring Mr. Halsey Gribness. I assured him that his red spot is not Lyme disease, adding that whatever bit him had more legs than he does. His honeymoon safari to Ecuador sounds special. Mrs. Gribness is recovering nicely. I simply can't thank you enough for allowing me to participate in the care of this most pleasant gentleman.

Collegially …

Far more often, though, no doctor played any role in encouraging the patient to show up; other, nonmedical sources did the job.

I would love to send notes acknowledging their referrals, too, but most of the time I don't know how to reach them. I will therefore devote my next two columns to thanking these referrers. I assume they subscribe to SKIN & ALLERGY NEWS. If they don't, they should.

Dear Parent/Significant Other:

Helping someone near and dear to overcome inertia takes resolute encouragement; the technical term for this is "nagging." Without your efforts, Ken might never have shown me that mole, and the thing on Jen's nose would have just kept on getting bigger.

Special thanks to the women among you, because you take the responsibility for health matters that your men secretly rely on while pretending to be annoyed.

Telling Stanley, "If you don't have that brown spot looked at, don't come home for Thanksgiving," was a bit strong, but love's got to be tough sometimes.

Keep up that resolute encouragement!

Dear Patient's Coworker:

Now that the water cooler has been replaced by the Intranet and instant messaging, you have so many more opportunities to share diagnostic and therapeutic advice. To tell the truth, I don't think I would discuss with my wife half the things my patients seem to have kicked around with the whole human resources department. You guys really know a lot! You've seen cases just like Bill's, recommended treatments you're sure are bound to work for rashes like Jill's, seen how things ended (usually badly) when growths like Phil's weren't taken care of in time.

Of course you don't even have to actually say anything to generate a visit to my office. Staring at the warts on Syl's hands as she typed at the adjacent keyboard, all the while maintaining a tactful silence, did the trick. So did squirming as Will scratched at the board meeting.

Keep those referrals coming!

Dear Hairdresser:

You guys and gals have a unique perspective—you stand over people and look down at a part of the body that is important but seldom seen. So when you say, "Mabel, you're really thinning out, I can see your scalp!" you get her attention. You pick up cases of psoriasis and alopecia people didn't know they had and spot moles they didn't know were there. You have great moral authority, too. If Hermione is wavering, telling her there is no way you'll take responsibility for putting a chemical color on that until a doctor says it's OK sends her right over to me.

If I had any hair, I would thank you in person.

Dear Magnifying Mirror:

Just when failing close-up vision threatens to make my patients ignore those minor imperfections, you step in to save the day. I looked at myself in one of you recently—scary! My pores looked like the far side of the moon, and the mottling under my eyes reminded me of potato blight. I'd consult myself if I could get a referral.

To be continued …

If you ask patients not just why they came but why they came now, you'll often find that a third party was involved. Whatever is wrong may have been there for some time, raising no concern in the patient's mind until someone else stared at it and warned, "You'd better get that taken care of!"

Now and then this is a colleague. In that case, I can write a letter acknowledging the referral:

Dear Chip,

Thanks so much for referring Mr. Halsey Gribness. I assured him that his red spot is not Lyme disease, adding that whatever bit him had more legs than he does. His honeymoon safari to Ecuador sounds special. Mrs. Gribness is recovering nicely. I simply can't thank you enough for allowing me to participate in the care of this most pleasant gentleman.

Collegially …

Far more often, though, no doctor played any role in encouraging the patient to show up; other, nonmedical sources did the job.

I would love to send notes acknowledging their referrals, too, but most of the time I don't know how to reach them. I will therefore devote my next two columns to thanking these referrers. I assume they subscribe to SKIN & ALLERGY NEWS. If they don't, they should.

Dear Parent/Significant Other:

Helping someone near and dear to overcome inertia takes resolute encouragement; the technical term for this is "nagging." Without your efforts, Ken might never have shown me that mole, and the thing on Jen's nose would have just kept on getting bigger.

Special thanks to the women among you, because you take the responsibility for health matters that your men secretly rely on while pretending to be annoyed.

Telling Stanley, "If you don't have that brown spot looked at, don't come home for Thanksgiving," was a bit strong, but love's got to be tough sometimes.

Keep up that resolute encouragement!

Dear Patient's Coworker:

Now that the water cooler has been replaced by the Intranet and instant messaging, you have so many more opportunities to share diagnostic and therapeutic advice. To tell the truth, I don't think I would discuss with my wife half the things my patients seem to have kicked around with the whole human resources department. You guys really know a lot! You've seen cases just like Bill's, recommended treatments you're sure are bound to work for rashes like Jill's, seen how things ended (usually badly) when growths like Phil's weren't taken care of in time.

Of course you don't even have to actually say anything to generate a visit to my office. Staring at the warts on Syl's hands as she typed at the adjacent keyboard, all the while maintaining a tactful silence, did the trick. So did squirming as Will scratched at the board meeting.

Keep those referrals coming!

Dear Hairdresser:

You guys and gals have a unique perspective—you stand over people and look down at a part of the body that is important but seldom seen. So when you say, "Mabel, you're really thinning out, I can see your scalp!" you get her attention. You pick up cases of psoriasis and alopecia people didn't know they had and spot moles they didn't know were there. You have great moral authority, too. If Hermione is wavering, telling her there is no way you'll take responsibility for putting a chemical color on that until a doctor says it's OK sends her right over to me.

If I had any hair, I would thank you in person.

Dear Magnifying Mirror:

Just when failing close-up vision threatens to make my patients ignore those minor imperfections, you step in to save the day. I looked at myself in one of you recently—scary! My pores looked like the far side of the moon, and the mottling under my eyes reminded me of potato blight. I'd consult myself if I could get a referral.

To be continued …

If you ask patients not just why they came but why they came now, you'll often find that a third party was involved. Whatever is wrong may have been there for some time, raising no concern in the patient's mind until someone else stared at it and warned, "You'd better get that taken care of!"

Now and then this is a colleague. In that case, I can write a letter acknowledging the referral:

Dear Chip,

Thanks so much for referring Mr. Halsey Gribness. I assured him that his red spot is not Lyme disease, adding that whatever bit him had more legs than he does. His honeymoon safari to Ecuador sounds special. Mrs. Gribness is recovering nicely. I simply can't thank you enough for allowing me to participate in the care of this most pleasant gentleman.

Collegially …

Far more often, though, no doctor played any role in encouraging the patient to show up; other, nonmedical sources did the job.

I would love to send notes acknowledging their referrals, too, but most of the time I don't know how to reach them. I will therefore devote my next two columns to thanking these referrers. I assume they subscribe to SKIN & ALLERGY NEWS. If they don't, they should.

Dear Parent/Significant Other:

Helping someone near and dear to overcome inertia takes resolute encouragement; the technical term for this is "nagging." Without your efforts, Ken might never have shown me that mole, and the thing on Jen's nose would have just kept on getting bigger.

Special thanks to the women among you, because you take the responsibility for health matters that your men secretly rely on while pretending to be annoyed.

Telling Stanley, "If you don't have that brown spot looked at, don't come home for Thanksgiving," was a bit strong, but love's got to be tough sometimes.

Keep up that resolute encouragement!

Dear Patient's Coworker:

Now that the water cooler has been replaced by the Intranet and instant messaging, you have so many more opportunities to share diagnostic and therapeutic advice. To tell the truth, I don't think I would discuss with my wife half the things my patients seem to have kicked around with the whole human resources department. You guys really know a lot! You've seen cases just like Bill's, recommended treatments you're sure are bound to work for rashes like Jill's, seen how things ended (usually badly) when growths like Phil's weren't taken care of in time.

Of course you don't even have to actually say anything to generate a visit to my office. Staring at the warts on Syl's hands as she typed at the adjacent keyboard, all the while maintaining a tactful silence, did the trick. So did squirming as Will scratched at the board meeting.

Keep those referrals coming!

Dear Hairdresser:

You guys and gals have a unique perspective—you stand over people and look down at a part of the body that is important but seldom seen. So when you say, "Mabel, you're really thinning out, I can see your scalp!" you get her attention. You pick up cases of psoriasis and alopecia people didn't know they had and spot moles they didn't know were there. You have great moral authority, too. If Hermione is wavering, telling her there is no way you'll take responsibility for putting a chemical color on that until a doctor says it's OK sends her right over to me.

If I had any hair, I would thank you in person.

Dear Magnifying Mirror:

Just when failing close-up vision threatens to make my patients ignore those minor imperfections, you step in to save the day. I looked at myself in one of you recently—scary! My pores looked like the far side of the moon, and the mottling under my eyes reminded me of potato blight. I'd consult myself if I could get a referral.

To be continued …

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

My last student confirmed it: Derm is indeed white hot. Only the very brightest dare apply, she told me, and even they face long odds. One of her top classmates who failed to match in dermatology has taken a year off to do the research he needs to buff his resume.

An earlier column that told of my experience hiring a physician assistant (PA) drew some strenuous responses ("Associates," September 2002, p. 10). A few of these accused dermatologists like me who engage so-called physician extenders—PAs and nurse-practitioners (NPs)—of irresponsible venality.

When my PA gave unexpected notice last year, I considered taking on a graduating dermatology resident. Directors at nearby training programs agreed to post my opportunity but said they weren't sure how many in their graduating cohort actually planned to enter practice. I got no bites.

Shortly after that I spoke with a consultant, who shared some statistics that I quote without being able to guarantee. He said the number of trainees sitting for the dermatology boards each year roughly approximates the number of practitioners who retire, but residents intending to practice are in fact much fewer. The rest, he said, "are interested in laser and Mohs."

Later in the year I had a chance to confirm these comments, if only anecdotally. Interviewing two men about to finish their training, I learned that several of their fellow residents were indeed heading for careers other than practice: cosmetic or Mohs fellowships, or leaves of absence for family reasons.

Attracting such applicants is indeed cause for optimism that a new generation of this caliber may make discoveries that will benefit patients and society at large. A small doubt, however, nags.

Caring for patients with everyday conditions offers many rewards and demands special skills, but high-octane intellect and entrepreneurial moxie are perhaps not among them.

If I am a super-bright young dermatologist with research credentials and interest, how will I view the quotidian task of managing acne, warts, and eczema?

Several trends therefore seem to point to this problem: If trainees see dermatology as an avenue to do exciting research, learn sophisticated technical skills, or advance lucrative cosmetic careers, then who will take care of the patients?

This is not a rhetorical question. In other countries dermatologists function as secondary or even tertiary consultants. Primary care of skin disease is the province of other practitioners. In principle, there is no reason internists, family physicians, and pediatricians shouldn't manage basic skin problems in the United States as well, but those of us who field referrals from these groups are continually amazed—and appalled—at what a poor job they often do.

The near absence of dermatology teaching in medical school explains a lot of this, of course; the standard curriculum imparts not just limited skin knowledge but an implicitly dismissive attitude toward caring for the banal complaints of ordinary people.

There should thus be no surprise at the burgeoning of "physician extenders" (a barbarous term that conjures up "Hamburger Helper"). Dermatology PAs have for some time had a vigorous organization, the Society of Dermatology Physician Assistants. Dermatology NPs are likewise getting their act together. Near Boston the prestigious Lahey Clinic Medical Center has a new training program for dermatology NPs.

What distinguishes such practitioners is that they actually want to do clinical work. They view caring for patients with everyday problems not as a distraction from their main career, but as its fulfillment. In light of evolving trends in dermatology training and practice, perhaps our profession ought to support and guide the proliferation of dermatology NPs and PAs rather than decrying or ignoring it.

If research provides new treatments, who will administer them? When patients need help, who will take care of them?

The man's complaint came as no surprise.

"Doctor, can you look at my molds?"

This is a common request that has minor variations. For instance, patients from the former British Commonwealth ask me to check their moulds.

"Did you ever have any removed?"

"Yes, but it was no problem. They did an autopsy."

I examined his back, looking for a scar. "Where were they taken off?"

"In Chicago."

"Who would have the test results?"

"I'm afraid I don't remember who removed them. It was a doctor."

"Do you have any allergies to medication?"

"I can't take any of the cillins. A pill they once gave me for roseola did a number on my stomach. Doxycillin, that was it."

"Is there a family history of skin cancer?"

"My Dad had several melanomas on his face. And my aunt had a different one. It wasn't the brash kind, it was more reticent … oh yes, a squeamish cell."

"Anybody else?"

"My cousin had something taken off too, but it was OK, just a karyotis."

"Have you had other skin problems?"

"Yes, I was treated with nitroglycerin for planter's warts. Some kind of fungus."

"Warts are a virus."

"Yes. And besides the fungus, I also had athlete's foot. The itch was terrible. I got a cream."

"Do you remember which one?"

"It came in a tube."

"Do you know the name?"

"It was white."

"Do you have a history of rashes?"

"Yes, I've had eczema for years."

"Any family history of eczema?"

"My uncle had psoriasis."

"Is your eczema pretty constant?"

"No, it comes and goes. At the change of seasons it tends to exasperate. Then I go to the doctor, and he describes something."

"Which helps?"

"Oh yes. Whenever there's an exasperation, I get a subscription and the eczema goes into recession."

"Which cream is that?"

"It comes in a tube."

"And it's white?"

"No, actually it's kind of clear. I think I remember the name … fluconide … flocunood … flucafloca … flinkanode …"

"Lidex?"

"That's it!"

"You're new to the practice. How did you find me?"

"You seem OK."

Discussions with patients can strongly impact me.

Sometimes it takes a couple of hours and a Jack Daniels on the rocks for me to be fully disimpacted.

The man's complaint came as no surprise.

"Doctor, can you look at my molds?"

This is a common request that has minor variations. For instance, patients from the former British Commonwealth ask me to check their moulds.

"Did you ever have any removed?"

"Yes, but it was no problem. They did an autopsy."

I examined his back, looking for a scar. "Where were they taken off?"

"In Chicago."

"Who would have the test results?"

"I'm afraid I don't remember who removed them. It was a doctor."

"Do you have any allergies to medication?"

"I can't take any of the cillins. A pill they once gave me for roseola did a number on my stomach. Doxycillin, that was it."

"Is there a family history of skin cancer?"

"My Dad had several melanomas on his face. And my aunt had a different one. It wasn't the brash kind, it was more reticent … oh yes, a squeamish cell."

"Anybody else?"

"My cousin had something taken off too, but it was OK, just a karyotis."

"Have you had other skin problems?"

"Yes, I was treated with nitroglycerin for planter's warts. Some kind of fungus."

"Warts are a virus."

"Yes. And besides the fungus, I also had athlete's foot. The itch was terrible. I got a cream."

"Do you remember which one?"

"It came in a tube."

"Do you know the name?"

"It was white."

"Do you have a history of rashes?"

"Yes, I've had eczema for years."

"Any family history of eczema?"

"My uncle had psoriasis."

"Is your eczema pretty constant?"

"No, it comes and goes. At the change of seasons it tends to exasperate. Then I go to the doctor, and he describes something."

"Which helps?"

"Oh yes. Whenever there's an exasperation, I get a subscription and the eczema goes into recession."

"Which cream is that?"

"It comes in a tube."

"And it's white?"

"No, actually it's kind of clear. I think I remember the name … fluconide … flocunood … flucafloca … flinkanode …"

"Lidex?"

"That's it!"

"You're new to the practice. How did you find me?"

"You seem OK."

Discussions with patients can strongly impact me.

Sometimes it takes a couple of hours and a Jack Daniels on the rocks for me to be fully disimpacted.

The man's complaint came as no surprise.

"Doctor, can you look at my molds?"

This is a common request that has minor variations. For instance, patients from the former British Commonwealth ask me to check their moulds.

"Did you ever have any removed?"

"Yes, but it was no problem. They did an autopsy."

I examined his back, looking for a scar. "Where were they taken off?"

"In Chicago."

"Who would have the test results?"

"I'm afraid I don't remember who removed them. It was a doctor."

"Do you have any allergies to medication?"

"I can't take any of the cillins. A pill they once gave me for roseola did a number on my stomach. Doxycillin, that was it."

"Is there a family history of skin cancer?"

"My Dad had several melanomas on his face. And my aunt had a different one. It wasn't the brash kind, it was more reticent … oh yes, a squeamish cell."

"Anybody else?"

"My cousin had something taken off too, but it was OK, just a karyotis."

"Have you had other skin problems?"

"Yes, I was treated with nitroglycerin for planter's warts. Some kind of fungus."

"Warts are a virus."

"Yes. And besides the fungus, I also had athlete's foot. The itch was terrible. I got a cream."

"Do you remember which one?"

"It came in a tube."

"Do you know the name?"

"It was white."

"Do you have a history of rashes?"

"Yes, I've had eczema for years."

"Any family history of eczema?"

"My uncle had psoriasis."

"Is your eczema pretty constant?"

"No, it comes and goes. At the change of seasons it tends to exasperate. Then I go to the doctor, and he describes something."

"Which helps?"

"Oh yes. Whenever there's an exasperation, I get a subscription and the eczema goes into recession."

"Which cream is that?"

"It comes in a tube."

"And it's white?"

"No, actually it's kind of clear. I think I remember the name … fluconide … flocunood … flucafloca … flinkanode …"

"Lidex?"

"That's it!"

"You're new to the practice. How did you find me?"

"You seem OK."

Discussions with patients can strongly impact me.

Sometimes it takes a couple of hours and a Jack Daniels on the rocks for me to be fully disimpacted.

I've just desiccated a tag on Reba's eyebrow. A moment later she says, "Ah, now my skin is starting to feel numb. Too bad I don't need it to be numb now." Then she pauses for effect: "Maybe next time we can wait for the anesthetic to start working."

Ouch.

Picture yourself walking down the street. You approach a passing stranger and stick a needle in his forehead.

Picture yourself at a party. At a conversation by the punchbowl, you spray a neighbor's nose with nitrogen.

Now picture yourself in handcuffs at the police station being arraigned for assault.

Hurting people is a routine part of our day; it's therefore worth a moment to consider that without an unstated social contract that lets us get away with (and charge for) this, the kind of assaults we commit would be actionable in any other setting.

This helps explain the way some patients react, even when—as in Reba's case—they didn't feel a thing.

Faced with the prospect of our imminent attack, people respond in several ways:

▸ Terror. "Will it hurt?" Well, of course it will, and they know it. Our usual breezy assurance ("Just a little mosquito bite!") tends to lack credibility.

▸ Apology. "I'm a terrible patient, Doctor." Consider the implications of this admission: We are about to stab, freeze, or broil, and they are running themselves down. Maybe we're the ones who should say, "I'm a terrible doctor, Patient."

▸ Interrogation. To forestall our onslaught some people resort to delaying tactics by asking questions like, "What kind of anesthetic do you use?" or "How big is the needle?" Children especially like this ploy: "Wait! What's that thing at the end of the bottle?" "Wait! Wait! How many seconds will you be freezing it?" (I usually say "6.2 seconds!" and do the deed while they're trying to figure out what I meant.)

▸ Scolding. The occasional patient likes to frame the issue in sociopolitical terms by delivering a little lecture on patients' rights and physicians' duties. "Doctor, I have a right to know exactly what you're doing, so you need to tell me everything you're going to do, step by step, before you do it." ("Now I am putting a 20-gauge needle onto the end of the syringe. Now I am holding the bottle of lidocaine upside down. Now I am …"—by this point they usually ask me to just get on with it.)

It's clear that all these questions, apologies, and demands are mostly declarations of fear and pleas for clemency. Although we can't, of course, grant a complete reprieve, all of us have methods for making things easier. We've all been using them since medical school: calm reassurance, testing numbness before needling, injecting slowly, and so forth. These don't take a lot of time, but since like all dermatologists I'm always in a rush, I have to remind myself to slow down and use them.

One exception is when assaulting children too young to reason with and too big to hold down. For these, I've found that it's often best to get things over with, pronto. More talk just makes for more terror.

It also seems that many people find it comforting to learn that our desiccation electrodes do not actually penetrate the skin. It's not just the fear of pain that frightens people (myself included) but the prospect of penetration that violates our body's integrity. Think about it by visualizing a needle heading your way, or try telling your patients, "The electric needle doesn't actually go in—it just touches you on the outside." Likewise, adhesive bandages help kids by shielding them from having to look at the way we've insulted their bodies by breaching its outer boundary.

Overall, it's perhaps worth keeping in mind that our procedural assaults are not just painful but scary and insulting. Anything we do to ease that is worth trying.

Meantime, we can celebrate the license society grants us to prick, prod, and poke people with impunity. Not only that, when our assault makes patients flinch, they apologize!

I've just desiccated a tag on Reba's eyebrow. A moment later she says, "Ah, now my skin is starting to feel numb. Too bad I don't need it to be numb now." Then she pauses for effect: "Maybe next time we can wait for the anesthetic to start working."

Ouch.

Picture yourself walking down the street. You approach a passing stranger and stick a needle in his forehead.

Picture yourself at a party. At a conversation by the punchbowl, you spray a neighbor's nose with nitrogen.

Now picture yourself in handcuffs at the police station being arraigned for assault.

Hurting people is a routine part of our day; it's therefore worth a moment to consider that without an unstated social contract that lets us get away with (and charge for) this, the kind of assaults we commit would be actionable in any other setting.

This helps explain the way some patients react, even when—as in Reba's case—they didn't feel a thing.

Faced with the prospect of our imminent attack, people respond in several ways:

▸ Terror. "Will it hurt?" Well, of course it will, and they know it. Our usual breezy assurance ("Just a little mosquito bite!") tends to lack credibility.

▸ Apology. "I'm a terrible patient, Doctor." Consider the implications of this admission: We are about to stab, freeze, or broil, and they are running themselves down. Maybe we're the ones who should say, "I'm a terrible doctor, Patient."

▸ Interrogation. To forestall our onslaught some people resort to delaying tactics by asking questions like, "What kind of anesthetic do you use?" or "How big is the needle?" Children especially like this ploy: "Wait! What's that thing at the end of the bottle?" "Wait! Wait! How many seconds will you be freezing it?" (I usually say "6.2 seconds!" and do the deed while they're trying to figure out what I meant.)

▸ Scolding. The occasional patient likes to frame the issue in sociopolitical terms by delivering a little lecture on patients' rights and physicians' duties. "Doctor, I have a right to know exactly what you're doing, so you need to tell me everything you're going to do, step by step, before you do it." ("Now I am putting a 20-gauge needle onto the end of the syringe. Now I am holding the bottle of lidocaine upside down. Now I am …"—by this point they usually ask me to just get on with it.)

It's clear that all these questions, apologies, and demands are mostly declarations of fear and pleas for clemency. Although we can't, of course, grant a complete reprieve, all of us have methods for making things easier. We've all been using them since medical school: calm reassurance, testing numbness before needling, injecting slowly, and so forth. These don't take a lot of time, but since like all dermatologists I'm always in a rush, I have to remind myself to slow down and use them.

One exception is when assaulting children too young to reason with and too big to hold down. For these, I've found that it's often best to get things over with, pronto. More talk just makes for more terror.

It also seems that many people find it comforting to learn that our desiccation electrodes do not actually penetrate the skin. It's not just the fear of pain that frightens people (myself included) but the prospect of penetration that violates our body's integrity. Think about it by visualizing a needle heading your way, or try telling your patients, "The electric needle doesn't actually go in—it just touches you on the outside." Likewise, adhesive bandages help kids by shielding them from having to look at the way we've insulted their bodies by breaching its outer boundary.

Overall, it's perhaps worth keeping in mind that our procedural assaults are not just painful but scary and insulting. Anything we do to ease that is worth trying.

Meantime, we can celebrate the license society grants us to prick, prod, and poke people with impunity. Not only that, when our assault makes patients flinch, they apologize!

I've just desiccated a tag on Reba's eyebrow. A moment later she says, "Ah, now my skin is starting to feel numb. Too bad I don't need it to be numb now." Then she pauses for effect: "Maybe next time we can wait for the anesthetic to start working."

Ouch.

Picture yourself walking down the street. You approach a passing stranger and stick a needle in his forehead.

Picture yourself at a party. At a conversation by the punchbowl, you spray a neighbor's nose with nitrogen.

Now picture yourself in handcuffs at the police station being arraigned for assault.

Hurting people is a routine part of our day; it's therefore worth a moment to consider that without an unstated social contract that lets us get away with (and charge for) this, the kind of assaults we commit would be actionable in any other setting.

This helps explain the way some patients react, even when—as in Reba's case—they didn't feel a thing.

Faced with the prospect of our imminent attack, people respond in several ways:

▸ Terror. "Will it hurt?" Well, of course it will, and they know it. Our usual breezy assurance ("Just a little mosquito bite!") tends to lack credibility.

▸ Apology. "I'm a terrible patient, Doctor." Consider the implications of this admission: We are about to stab, freeze, or broil, and they are running themselves down. Maybe we're the ones who should say, "I'm a terrible doctor, Patient."

▸ Interrogation. To forestall our onslaught some people resort to delaying tactics by asking questions like, "What kind of anesthetic do you use?" or "How big is the needle?" Children especially like this ploy: "Wait! What's that thing at the end of the bottle?" "Wait! Wait! How many seconds will you be freezing it?" (I usually say "6.2 seconds!" and do the deed while they're trying to figure out what I meant.)

▸ Scolding. The occasional patient likes to frame the issue in sociopolitical terms by delivering a little lecture on patients' rights and physicians' duties. "Doctor, I have a right to know exactly what you're doing, so you need to tell me everything you're going to do, step by step, before you do it." ("Now I am putting a 20-gauge needle onto the end of the syringe. Now I am holding the bottle of lidocaine upside down. Now I am …"—by this point they usually ask me to just get on with it.)

It's clear that all these questions, apologies, and demands are mostly declarations of fear and pleas for clemency. Although we can't, of course, grant a complete reprieve, all of us have methods for making things easier. We've all been using them since medical school: calm reassurance, testing numbness before needling, injecting slowly, and so forth. These don't take a lot of time, but since like all dermatologists I'm always in a rush, I have to remind myself to slow down and use them.

One exception is when assaulting children too young to reason with and too big to hold down. For these, I've found that it's often best to get things over with, pronto. More talk just makes for more terror.

It also seems that many people find it comforting to learn that our desiccation electrodes do not actually penetrate the skin. It's not just the fear of pain that frightens people (myself included) but the prospect of penetration that violates our body's integrity. Think about it by visualizing a needle heading your way, or try telling your patients, "The electric needle doesn't actually go in—it just touches you on the outside." Likewise, adhesive bandages help kids by shielding them from having to look at the way we've insulted their bodies by breaching its outer boundary.

Overall, it's perhaps worth keeping in mind that our procedural assaults are not just painful but scary and insulting. Anything we do to ease that is worth trying.

Meantime, we can celebrate the license society grants us to prick, prod, and poke people with impunity. Not only that, when our assault makes patients flinch, they apologize!

It took me a while to catch on.

My first hint came at a free skin cancer screening years ago at our city hall. I noticed that not all the patients who came were the uninsured with no medical access. Many had dermatologists. Many had me.

"What about this dark spot, Doctor?"

"It's a seborrheic keratosis, Mrs. Jacobs. Completely benign."

"That's what you said at my last visit. I just wanted to see if it's still OK."

Fast forward to last Thursday. Dale is worried about some spots on her face.

"The ones on your chin are keratoses," I explain. "They're fine. And the flat ones on your cheeks are also no problem. If they don't bother you, they can stay."

Dale expresses relief. We chat for a few minutes, catch up on things. Then her eyes narrow. "Ah, tell me, Doctor … these spots could never become … cancerous, could they?"

Here then is another instance of how patients view and categorize the world in ways that can't be translated into the way we do. Simply put, to us a lesion is either benign or malignant. To patients a spot is either malignant, or not yet malignant.

Perhaps we're suspicious about a lesion and perform a biopsy. The biopsy is benign. We delightedly report the good news. The patient is happy, too, but just provisionally. Sure it's not cancer—today. Tomorrow, who knows?

Of course even in our scheme benign nevi can sometimes turn cancerous, but that uncommon transformation is not what worries patients. After all, every day we see things that never, ever turn bad, which can't do so even in theory—seborrheic keratoses, dermal nevi, dermatofibromas. For our patients, however, even these are potential malefactors who got off on a technicality. Better be vigilant; they could come back.

The difference between the way we look at things and the way our patients do is the difference between a thing and a process. To us, a lesion is a collection of cells—melanocytes, keratinocytes, and so forth. Each collection has an identity and an expected biologic fate. We look at all diseases that way too, and call them "entities."

To patients, a lesion is not a thing in itself but a deviation from what used to be—an instability. The skin used to be clear; now there's something there. Something is going on. Once that starts to happen, who's to say it won't keep happening, leading finally to the ultimate instability—cancer.

No need to take my word for any of this. The next time (in 10 minutes?) you see a patient worried about a benign spot, try saying something like: "We call this a dermal nevus, Mr. Perkins. It's completely benign." Then pause for effect and add, "and it will always be benign."

Watch his eyes widen in surprise. This is indeed news. "You mean it will always be nothing to worry about? I had no idea."

Of course, some people are more anxious about instability than are others. But if you look for this reaction, it shouldn't take long to recognize that many people with ordinary moles, keratoses, and skin tags are just not assuaged by a bland reassurance that all is well. Like Dale, quoted earlier, they retain a level of unresolved suspicion.

What to do? A few suggestions:

▸ Avoid advising patients to "Keep an eye on it." That implies you, too, have your doubts. If you do, either keep an eye on it yourself or take it off.

▸ Assure people that trauma—bra or neck chain rubbing, sun exposure—doesn't make benign things malignant. (This widespread conviction flows from the fact that swelling and bleeding imply even more dangerous instability.)

▸ Sometimes the expressed anxiety of a spouse or primary physician makes it impossible to reassure someone about a specific spot. Unless logistics dictate otherwise, it's often better in such cases to just take the damned thing off and be done with it.

Then call to say it's benign. And now that it's out, it will always stay that way.

It took me a while to catch on.

My first hint came at a free skin cancer screening years ago at our city hall. I noticed that not all the patients who came were the uninsured with no medical access. Many had dermatologists. Many had me.

"What about this dark spot, Doctor?"

"It's a seborrheic keratosis, Mrs. Jacobs. Completely benign."

"That's what you said at my last visit. I just wanted to see if it's still OK."

Fast forward to last Thursday. Dale is worried about some spots on her face.

"The ones on your chin are keratoses," I explain. "They're fine. And the flat ones on your cheeks are also no problem. If they don't bother you, they can stay."

Dale expresses relief. We chat for a few minutes, catch up on things. Then her eyes narrow. "Ah, tell me, Doctor … these spots could never become … cancerous, could they?"

Here then is another instance of how patients view and categorize the world in ways that can't be translated into the way we do. Simply put, to us a lesion is either benign or malignant. To patients a spot is either malignant, or not yet malignant.

Perhaps we're suspicious about a lesion and perform a biopsy. The biopsy is benign. We delightedly report the good news. The patient is happy, too, but just provisionally. Sure it's not cancer—today. Tomorrow, who knows?

Of course even in our scheme benign nevi can sometimes turn cancerous, but that uncommon transformation is not what worries patients. After all, every day we see things that never, ever turn bad, which can't do so even in theory—seborrheic keratoses, dermal nevi, dermatofibromas. For our patients, however, even these are potential malefactors who got off on a technicality. Better be vigilant; they could come back.

The difference between the way we look at things and the way our patients do is the difference between a thing and a process. To us, a lesion is a collection of cells—melanocytes, keratinocytes, and so forth. Each collection has an identity and an expected biologic fate. We look at all diseases that way too, and call them "entities."

To patients, a lesion is not a thing in itself but a deviation from what used to be—an instability. The skin used to be clear; now there's something there. Something is going on. Once that starts to happen, who's to say it won't keep happening, leading finally to the ultimate instability—cancer.

No need to take my word for any of this. The next time (in 10 minutes?) you see a patient worried about a benign spot, try saying something like: "We call this a dermal nevus, Mr. Perkins. It's completely benign." Then pause for effect and add, "and it will always be benign."

Watch his eyes widen in surprise. This is indeed news. "You mean it will always be nothing to worry about? I had no idea."

Of course, some people are more anxious about instability than are others. But if you look for this reaction, it shouldn't take long to recognize that many people with ordinary moles, keratoses, and skin tags are just not assuaged by a bland reassurance that all is well. Like Dale, quoted earlier, they retain a level of unresolved suspicion.

What to do? A few suggestions:

▸ Avoid advising patients to "Keep an eye on it." That implies you, too, have your doubts. If you do, either keep an eye on it yourself or take it off.

▸ Assure people that trauma—bra or neck chain rubbing, sun exposure—doesn't make benign things malignant. (This widespread conviction flows from the fact that swelling and bleeding imply even more dangerous instability.)

▸ Sometimes the expressed anxiety of a spouse or primary physician makes it impossible to reassure someone about a specific spot. Unless logistics dictate otherwise, it's often better in such cases to just take the damned thing off and be done with it.

Then call to say it's benign. And now that it's out, it will always stay that way.

It took me a while to catch on.

My first hint came at a free skin cancer screening years ago at our city hall. I noticed that not all the patients who came were the uninsured with no medical access. Many had dermatologists. Many had me.

"What about this dark spot, Doctor?"

"It's a seborrheic keratosis, Mrs. Jacobs. Completely benign."

"That's what you said at my last visit. I just wanted to see if it's still OK."

Fast forward to last Thursday. Dale is worried about some spots on her face.

"The ones on your chin are keratoses," I explain. "They're fine. And the flat ones on your cheeks are also no problem. If they don't bother you, they can stay."

Dale expresses relief. We chat for a few minutes, catch up on things. Then her eyes narrow. "Ah, tell me, Doctor … these spots could never become … cancerous, could they?"

Here then is another instance of how patients view and categorize the world in ways that can't be translated into the way we do. Simply put, to us a lesion is either benign or malignant. To patients a spot is either malignant, or not yet malignant.

Perhaps we're suspicious about a lesion and perform a biopsy. The biopsy is benign. We delightedly report the good news. The patient is happy, too, but just provisionally. Sure it's not cancer—today. Tomorrow, who knows?

Of course even in our scheme benign nevi can sometimes turn cancerous, but that uncommon transformation is not what worries patients. After all, every day we see things that never, ever turn bad, which can't do so even in theory—seborrheic keratoses, dermal nevi, dermatofibromas. For our patients, however, even these are potential malefactors who got off on a technicality. Better be vigilant; they could come back.

The difference between the way we look at things and the way our patients do is the difference between a thing and a process. To us, a lesion is a collection of cells—melanocytes, keratinocytes, and so forth. Each collection has an identity and an expected biologic fate. We look at all diseases that way too, and call them "entities."

To patients, a lesion is not a thing in itself but a deviation from what used to be—an instability. The skin used to be clear; now there's something there. Something is going on. Once that starts to happen, who's to say it won't keep happening, leading finally to the ultimate instability—cancer.

No need to take my word for any of this. The next time (in 10 minutes?) you see a patient worried about a benign spot, try saying something like: "We call this a dermal nevus, Mr. Perkins. It's completely benign." Then pause for effect and add, "and it will always be benign."

Watch his eyes widen in surprise. This is indeed news. "You mean it will always be nothing to worry about? I had no idea."

Of course, some people are more anxious about instability than are others. But if you look for this reaction, it shouldn't take long to recognize that many people with ordinary moles, keratoses, and skin tags are just not assuaged by a bland reassurance that all is well. Like Dale, quoted earlier, they retain a level of unresolved suspicion.

What to do? A few suggestions:

▸ Avoid advising patients to "Keep an eye on it." That implies you, too, have your doubts. If you do, either keep an eye on it yourself or take it off.

▸ Assure people that trauma—bra or neck chain rubbing, sun exposure—doesn't make benign things malignant. (This widespread conviction flows from the fact that swelling and bleeding imply even more dangerous instability.)

▸ Sometimes the expressed anxiety of a spouse or primary physician makes it impossible to reassure someone about a specific spot. Unless logistics dictate otherwise, it's often better in such cases to just take the damned thing off and be done with it.

Then call to say it's benign. And now that it's out, it will always stay that way.

Ah, Monday morning. Time to check e-mails from far-flung patients. Miranda, a music major at Michigan, will remind me about her mometasone. Murray's mellowing on Minocin in Morocco.

Goodness, that inbox has certainly filled up over the weekend. What's this? Mortgage rates are that low? Wouldn't you know it—we just refinanced!

Look, I've been preapproved for credit. We have enough credit cards already, thanks.

Hmm, I knew they're importing medications from Canada and Mexico, but what kind of quality controls do they have in Bulgaria? Let's see, they're running a special on phentermine. Looks like a good price. I wonder what phentermine is. What else do they have … narcotics, anxiolytics … never mind. Why no topical steroids?

Finally, an e-mail from a patient! Don't recognize the name, though. I think I'd remember someone named Dirk Centagord. He's just canceling an appointment … what's this? This Dirk sure needs an editor. What kind of message is, "stethoscope mercy brunhilde huzzah buffalo carson allure?"

Now what? Look, I'm a physician, so don't expect me to believe you can change the size of anything with a cream. Besides, size doesn't matter. It does? She would? I never thought about it. … More drugs for sale. Judging by TV ads and cyberpromotions, half the world has fungal toenails and the other half has erectile dysfunction.

Another patient confirming an appointment. … Thelma Fontenot? A Rolex for $9.95? I wonder if it's genuine.

OK, knock it off—I got the mortgage stuff already. And phentermine, too. I'm just going to delete this stuff. Mortgage, delete. Credit cards, delete. Viagra, delete. Latin gibberish, delete. This is fun! Levitra, Cialis, Vicodin, delete, delete, delete. Ha! Hold on a second. … I think one of those messages I just deleted was the one I was waiting for from Miranda in Michigan. Great, how am I going to find it in the 3,000 messages in the deleted folder?

It's too bad. E-mail could be such a nice way to communicate. No phone tag, no trying to find a good time to call in a different time zone, no interruptions in the middle of patients. I installed a spam filter, but it worked so well that I couldn't even e-mail myself from home. How would I know if a patient tried to reach me and got his or her message blocked?

Now what? Great, first they enlarge you, then they shrink you back down. Alice in Wonderland had nothing on these guys. A revolutionary new diet pill that makes you lose up to 30 pounds in 30 days or less, automatically while you sleep? Body wrap at home to lose 6-20 inches in 1 hour! Put lindane under that overnight, and the scabies mites won't even find you in the morning.

Gustavo Fontenot? Must be Thelma's cousin from Caracas. … What? "Sehr geehrte Damen und Herren, die Weihnachtszeit naht und haben wir sicherlich noch einen guten Tipp!" Hey, Gustavo, I'll give you a guten Tipp in your guten Keester! A monkeypox on all the Fontenots. …

Another canceled appointment? Hey, fool me once—Paris Hilton is not a real name! Video? What video?

More credit card come-ons. Look at that, they're coming in bunches, 5 in a row, 10 in a row, 50, same message. More mortgages, 10, 20, 50, REFINANCE NOW, REFINANCE NOW, REFINANCE NOW. … Buy a Rolex, buy a Seiko, buy Vicodin, buy Cialis. The e-mails are like locusts, I can't kill them fast enough. … I don't want any of those drugs! Nobody by that name missed an appointment! I'm not going to update personal information for a bank I never heard of! I'm not shrinking or enlarging anything! How am I supposed to respond to marion allegiant asphalt tallyho torture confrontation? I refuse to answer Verzieren Sie die Uhr mit einer Gravur und sie warden! They're coming faster and faster. … I can't see the screen … everything's going black. OK, that's it, I'm bailing out, I'm deleting the whole Outlook. Mayday! Mayday! SOS! Abort! Abort! Control! Select All! Alt! DELETE, DELETE, DELETE. …

Darn—I think I deleted Murray.

Ah, Monday morning. Time to check e-mails from far-flung patients. Miranda, a music major at Michigan, will remind me about her mometasone. Murray's mellowing on Minocin in Morocco.

Goodness, that inbox has certainly filled up over the weekend. What's this? Mortgage rates are that low? Wouldn't you know it—we just refinanced!

Look, I've been preapproved for credit. We have enough credit cards already, thanks.

Hmm, I knew they're importing medications from Canada and Mexico, but what kind of quality controls do they have in Bulgaria? Let's see, they're running a special on phentermine. Looks like a good price. I wonder what phentermine is. What else do they have … narcotics, anxiolytics … never mind. Why no topical steroids?

Finally, an e-mail from a patient! Don't recognize the name, though. I think I'd remember someone named Dirk Centagord. He's just canceling an appointment … what's this? This Dirk sure needs an editor. What kind of message is, "stethoscope mercy brunhilde huzzah buffalo carson allure?"

Now what? Look, I'm a physician, so don't expect me to believe you can change the size of anything with a cream. Besides, size doesn't matter. It does? She would? I never thought about it. … More drugs for sale. Judging by TV ads and cyberpromotions, half the world has fungal toenails and the other half has erectile dysfunction.

Another patient confirming an appointment. … Thelma Fontenot? A Rolex for $9.95? I wonder if it's genuine.

OK, knock it off—I got the mortgage stuff already. And phentermine, too. I'm just going to delete this stuff. Mortgage, delete. Credit cards, delete. Viagra, delete. Latin gibberish, delete. This is fun! Levitra, Cialis, Vicodin, delete, delete, delete. Ha! Hold on a second. … I think one of those messages I just deleted was the one I was waiting for from Miranda in Michigan. Great, how am I going to find it in the 3,000 messages in the deleted folder?

It's too bad. E-mail could be such a nice way to communicate. No phone tag, no trying to find a good time to call in a different time zone, no interruptions in the middle of patients. I installed a spam filter, but it worked so well that I couldn't even e-mail myself from home. How would I know if a patient tried to reach me and got his or her message blocked?

Now what? Great, first they enlarge you, then they shrink you back down. Alice in Wonderland had nothing on these guys. A revolutionary new diet pill that makes you lose up to 30 pounds in 30 days or less, automatically while you sleep? Body wrap at home to lose 6-20 inches in 1 hour! Put lindane under that overnight, and the scabies mites won't even find you in the morning.

Gustavo Fontenot? Must be Thelma's cousin from Caracas. … What? "Sehr geehrte Damen und Herren, die Weihnachtszeit naht und haben wir sicherlich noch einen guten Tipp!" Hey, Gustavo, I'll give you a guten Tipp in your guten Keester! A monkeypox on all the Fontenots. …

Another canceled appointment? Hey, fool me once—Paris Hilton is not a real name! Video? What video?

More credit card come-ons. Look at that, they're coming in bunches, 5 in a row, 10 in a row, 50, same message. More mortgages, 10, 20, 50, REFINANCE NOW, REFINANCE NOW, REFINANCE NOW. … Buy a Rolex, buy a Seiko, buy Vicodin, buy Cialis. The e-mails are like locusts, I can't kill them fast enough. … I don't want any of those drugs! Nobody by that name missed an appointment! I'm not going to update personal information for a bank I never heard of! I'm not shrinking or enlarging anything! How am I supposed to respond to marion allegiant asphalt tallyho torture confrontation? I refuse to answer Verzieren Sie die Uhr mit einer Gravur und sie warden! They're coming faster and faster. … I can't see the screen … everything's going black. OK, that's it, I'm bailing out, I'm deleting the whole Outlook. Mayday! Mayday! SOS! Abort! Abort! Control! Select All! Alt! DELETE, DELETE, DELETE. …

Darn—I think I deleted Murray.

Ah, Monday morning. Time to check e-mails from far-flung patients. Miranda, a music major at Michigan, will remind me about her mometasone. Murray's mellowing on Minocin in Morocco.

Goodness, that inbox has certainly filled up over the weekend. What's this? Mortgage rates are that low? Wouldn't you know it—we just refinanced!

Look, I've been preapproved for credit. We have enough credit cards already, thanks.

Hmm, I knew they're importing medications from Canada and Mexico, but what kind of quality controls do they have in Bulgaria? Let's see, they're running a special on phentermine. Looks like a good price. I wonder what phentermine is. What else do they have … narcotics, anxiolytics … never mind. Why no topical steroids?

Finally, an e-mail from a patient! Don't recognize the name, though. I think I'd remember someone named Dirk Centagord. He's just canceling an appointment … what's this? This Dirk sure needs an editor. What kind of message is, "stethoscope mercy brunhilde huzzah buffalo carson allure?"

Now what? Look, I'm a physician, so don't expect me to believe you can change the size of anything with a cream. Besides, size doesn't matter. It does? She would? I never thought about it. … More drugs for sale. Judging by TV ads and cyberpromotions, half the world has fungal toenails and the other half has erectile dysfunction.

Another patient confirming an appointment. … Thelma Fontenot? A Rolex for $9.95? I wonder if it's genuine.

OK, knock it off—I got the mortgage stuff already. And phentermine, too. I'm just going to delete this stuff. Mortgage, delete. Credit cards, delete. Viagra, delete. Latin gibberish, delete. This is fun! Levitra, Cialis, Vicodin, delete, delete, delete. Ha! Hold on a second. … I think one of those messages I just deleted was the one I was waiting for from Miranda in Michigan. Great, how am I going to find it in the 3,000 messages in the deleted folder?

It's too bad. E-mail could be such a nice way to communicate. No phone tag, no trying to find a good time to call in a different time zone, no interruptions in the middle of patients. I installed a spam filter, but it worked so well that I couldn't even e-mail myself from home. How would I know if a patient tried to reach me and got his or her message blocked?

Now what? Great, first they enlarge you, then they shrink you back down. Alice in Wonderland had nothing on these guys. A revolutionary new diet pill that makes you lose up to 30 pounds in 30 days or less, automatically while you sleep? Body wrap at home to lose 6-20 inches in 1 hour! Put lindane under that overnight, and the scabies mites won't even find you in the morning.

Gustavo Fontenot? Must be Thelma's cousin from Caracas. … What? "Sehr geehrte Damen und Herren, die Weihnachtszeit naht und haben wir sicherlich noch einen guten Tipp!" Hey, Gustavo, I'll give you a guten Tipp in your guten Keester! A monkeypox on all the Fontenots. …

Another canceled appointment? Hey, fool me once—Paris Hilton is not a real name! Video? What video?

More credit card come-ons. Look at that, they're coming in bunches, 5 in a row, 10 in a row, 50, same message. More mortgages, 10, 20, 50, REFINANCE NOW, REFINANCE NOW, REFINANCE NOW. … Buy a Rolex, buy a Seiko, buy Vicodin, buy Cialis. The e-mails are like locusts, I can't kill them fast enough. … I don't want any of those drugs! Nobody by that name missed an appointment! I'm not going to update personal information for a bank I never heard of! I'm not shrinking or enlarging anything! How am I supposed to respond to marion allegiant asphalt tallyho torture confrontation? I refuse to answer Verzieren Sie die Uhr mit einer Gravur und sie warden! They're coming faster and faster. … I can't see the screen … everything's going black. OK, that's it, I'm bailing out, I'm deleting the whole Outlook. Mayday! Mayday! SOS! Abort! Abort! Control! Select All! Alt! DELETE, DELETE, DELETE. …

Darn—I think I deleted Murray.

"I say, Holmes," I said, "how did you deduce that my last patient was a devotee of Alternative Medicine?"

"Elementary, my dear Rocky," he replied. Even Holmes grows informal with the times. "First, I observed that she'd brought a bottle of calendula, an emollient with cachet among those who prefer their remedies natural.

"Second, I observed that her address was in the vicinity of Harvard Square, a district rife with holistic clinics, purveyors of supplements, and establishments where cleansing detoxification may be procured.

"More important," he continued, "take note of her historical narrative. Attributing a similar rash last year to the water in her Cape Cod cape, she had showered exclusively at her health club. What disturbed her was that the affliction returned despite continued remote bathing. Blaming disease on diet and environment is a staple of Alternative thinking.

"What clinched the matter," Holmes continued, warming to his subject, "was her opening challenge to you. 'Don't just treat the symptoms,' she said, 'Get to the root cause!' The term, 'root cause,' capsulizes Alternative healing's central critique of Western medicine—that you paper over symptoms and fail to address the true source, which must come from the approved list of usual suspects: diet, water, atmosphere, hygiene, allergy. Demanding a 'root cause,' Rocky—et voilá!"

"Capital, Holmes!" I enthused.

He ignored me, as usual. "You physicians," Holmes continued, "often discuss Alternative therapies as though all that matters is whether they 'work.' This question is far too narrow, and misses the point that the Alternative world is in fact a subculture with a package of ideas linked as much by sociology as logic."

"Such as?" I inquired.

"Such as preferring nature to artifice. Such as rejecting analysis—the body as an aggregate of specific organs and systems—in favor of synthesis—the body as a whole. When you allopathic physicians diagnose a condition eczema and call it a 'skin disease,' Alternatives bristle, insisting as an article of faith that what appears on the skin must be 'systemic,' that is, must reflect what goes on within.

"This is a very old notion. Consider the word, 'eruption.' What do you think is erupting and where is it erupting from? An abnormal surface is assumed to reflect what the body has extruded in an effort to balance the humors roiling within. One stuffs it back down through the pores at peril. Hence the often-heard question, 'If you clear up the rash here, won't it just pop out somewhere else?'"

"Holmes!" I exclaimed. "Could your discussion be an instance of what has been called 'Cultural Competence' by the New England Journal of Medicine (N. Engl. J. Med. 2004;351:953–5)?"

"My subscription lapsed," Holmes sniffed. "In any case, people may express alien cultural ideas in perfect English. One ought to address members of the Alternative culture, as those of any tradition, with care and forethought."

"Have you any suggestions?" I ventured.

"Four," came his crisp retort. "First, candidly admit that you often don't know root causes. Suggest instead alleviating symptoms as a limited yet worthwhile goal.

"Second, use steroids, the Alternative's archnemesis, with discretion. If you must prescribe them, explain that circulating adrenal steroid hormones are natural, with any increment from percutaneous absorption all but imperceptible to the body.

"Third, concede the role of diet and environment, adding that this role is often erratic and individual. Advise patients to avoid what they themselves observe to consistently reproduce symptoms (shower water, for instance).

"Finally, endorse lay therapies when you have no reason not to. Aver that echinacea may be just the thing, that tea tree oil makes a lovely shampoo."

"Will this approach work?" I inquired.

"Usually," said Holmes. "Few people are doctrinally consistent about anything. Besides, a pure Alternative would not be in your office.

"As they say in the garment trade," he concluded with a flourish, "you gotta know your customers."

"Gadzooks, Holmes!" I expostulated. "This barbarous colloquialism has gone too far!"

Alas, too late. I gaped as Holmes exchanged his deerstalker for a Red Sox World Series cap, which he pulled on backwards.

"Chill, Rocky," said Holmes, with a thin smile. Turning to leave, he flipped me a small phial. "Have some of this chamomile. Calm you right down.

"I say, Holmes," I said, "how did you deduce that my last patient was a devotee of Alternative Medicine?"

"Elementary, my dear Rocky," he replied. Even Holmes grows informal with the times. "First, I observed that she'd brought a bottle of calendula, an emollient with cachet among those who prefer their remedies natural.

"Second, I observed that her address was in the vicinity of Harvard Square, a district rife with holistic clinics, purveyors of supplements, and establishments where cleansing detoxification may be procured.

"More important," he continued, "take note of her historical narrative. Attributing a similar rash last year to the water in her Cape Cod cape, she had showered exclusively at her health club. What disturbed her was that the affliction returned despite continued remote bathing. Blaming disease on diet and environment is a staple of Alternative thinking.

"What clinched the matter," Holmes continued, warming to his subject, "was her opening challenge to you. 'Don't just treat the symptoms,' she said, 'Get to the root cause!' The term, 'root cause,' capsulizes Alternative healing's central critique of Western medicine—that you paper over symptoms and fail to address the true source, which must come from the approved list of usual suspects: diet, water, atmosphere, hygiene, allergy. Demanding a 'root cause,' Rocky—et voilá!"

"Capital, Holmes!" I enthused.

He ignored me, as usual. "You physicians," Holmes continued, "often discuss Alternative therapies as though all that matters is whether they 'work.' This question is far too narrow, and misses the point that the Alternative world is in fact a subculture with a package of ideas linked as much by sociology as logic."

"Such as?" I inquired.

"Such as preferring nature to artifice. Such as rejecting analysis—the body as an aggregate of specific organs and systems—in favor of synthesis—the body as a whole. When you allopathic physicians diagnose a condition eczema and call it a 'skin disease,' Alternatives bristle, insisting as an article of faith that what appears on the skin must be 'systemic,' that is, must reflect what goes on within.

"This is a very old notion. Consider the word, 'eruption.' What do you think is erupting and where is it erupting from? An abnormal surface is assumed to reflect what the body has extruded in an effort to balance the humors roiling within. One stuffs it back down through the pores at peril. Hence the often-heard question, 'If you clear up the rash here, won't it just pop out somewhere else?'"

"Holmes!" I exclaimed. "Could your discussion be an instance of what has been called 'Cultural Competence' by the New England Journal of Medicine (N. Engl. J. Med. 2004;351:953–5)?"

"My subscription lapsed," Holmes sniffed. "In any case, people may express alien cultural ideas in perfect English. One ought to address members of the Alternative culture, as those of any tradition, with care and forethought."

"Have you any suggestions?" I ventured.

"Four," came his crisp retort. "First, candidly admit that you often don't know root causes. Suggest instead alleviating symptoms as a limited yet worthwhile goal.

"Second, use steroids, the Alternative's archnemesis, with discretion. If you must prescribe them, explain that circulating adrenal steroid hormones are natural, with any increment from percutaneous absorption all but imperceptible to the body.

"Third, concede the role of diet and environment, adding that this role is often erratic and individual. Advise patients to avoid what they themselves observe to consistently reproduce symptoms (shower water, for instance).

"Finally, endorse lay therapies when you have no reason not to. Aver that echinacea may be just the thing, that tea tree oil makes a lovely shampoo."

"Will this approach work?" I inquired.

"Usually," said Holmes. "Few people are doctrinally consistent about anything. Besides, a pure Alternative would not be in your office.

"As they say in the garment trade," he concluded with a flourish, "you gotta know your customers."

"Gadzooks, Holmes!" I expostulated. "This barbarous colloquialism has gone too far!"

Alas, too late. I gaped as Holmes exchanged his deerstalker for a Red Sox World Series cap, which he pulled on backwards.

"Chill, Rocky," said Holmes, with a thin smile. Turning to leave, he flipped me a small phial. "Have some of this chamomile. Calm you right down.

"I say, Holmes," I said, "how did you deduce that my last patient was a devotee of Alternative Medicine?"

"Elementary, my dear Rocky," he replied. Even Holmes grows informal with the times. "First, I observed that she'd brought a bottle of calendula, an emollient with cachet among those who prefer their remedies natural.

"Second, I observed that her address was in the vicinity of Harvard Square, a district rife with holistic clinics, purveyors of supplements, and establishments where cleansing detoxification may be procured.

"More important," he continued, "take note of her historical narrative. Attributing a similar rash last year to the water in her Cape Cod cape, she had showered exclusively at her health club. What disturbed her was that the affliction returned despite continued remote bathing. Blaming disease on diet and environment is a staple of Alternative thinking.

"What clinched the matter," Holmes continued, warming to his subject, "was her opening challenge to you. 'Don't just treat the symptoms,' she said, 'Get to the root cause!' The term, 'root cause,' capsulizes Alternative healing's central critique of Western medicine—that you paper over symptoms and fail to address the true source, which must come from the approved list of usual suspects: diet, water, atmosphere, hygiene, allergy. Demanding a 'root cause,' Rocky—et voilá!"

"Capital, Holmes!" I enthused.

He ignored me, as usual. "You physicians," Holmes continued, "often discuss Alternative therapies as though all that matters is whether they 'work.' This question is far too narrow, and misses the point that the Alternative world is in fact a subculture with a package of ideas linked as much by sociology as logic."

"Such as?" I inquired.

"Such as preferring nature to artifice. Such as rejecting analysis—the body as an aggregate of specific organs and systems—in favor of synthesis—the body as a whole. When you allopathic physicians diagnose a condition eczema and call it a 'skin disease,' Alternatives bristle, insisting as an article of faith that what appears on the skin must be 'systemic,' that is, must reflect what goes on within.

"This is a very old notion. Consider the word, 'eruption.' What do you think is erupting and where is it erupting from? An abnormal surface is assumed to reflect what the body has extruded in an effort to balance the humors roiling within. One stuffs it back down through the pores at peril. Hence the often-heard question, 'If you clear up the rash here, won't it just pop out somewhere else?'"

"Holmes!" I exclaimed. "Could your discussion be an instance of what has been called 'Cultural Competence' by the New England Journal of Medicine (N. Engl. J. Med. 2004;351:953–5)?"

"My subscription lapsed," Holmes sniffed. "In any case, people may express alien cultural ideas in perfect English. One ought to address members of the Alternative culture, as those of any tradition, with care and forethought."

"Have you any suggestions?" I ventured.

"Four," came his crisp retort. "First, candidly admit that you often don't know root causes. Suggest instead alleviating symptoms as a limited yet worthwhile goal.

"Second, use steroids, the Alternative's archnemesis, with discretion. If you must prescribe them, explain that circulating adrenal steroid hormones are natural, with any increment from percutaneous absorption all but imperceptible to the body.

"Third, concede the role of diet and environment, adding that this role is often erratic and individual. Advise patients to avoid what they themselves observe to consistently reproduce symptoms (shower water, for instance).

"Finally, endorse lay therapies when you have no reason not to. Aver that echinacea may be just the thing, that tea tree oil makes a lovely shampoo."

"Will this approach work?" I inquired.

"Usually," said Holmes. "Few people are doctrinally consistent about anything. Besides, a pure Alternative would not be in your office.

"As they say in the garment trade," he concluded with a flourish, "you gotta know your customers."

"Gadzooks, Holmes!" I expostulated. "This barbarous colloquialism has gone too far!"

Alas, too late. I gaped as Holmes exchanged his deerstalker for a Red Sox World Series cap, which he pulled on backwards.

"Chill, Rocky," said Holmes, with a thin smile. Turning to leave, he flipped me a small phial. "Have some of this chamomile. Calm you right down.

A jammed sharps container doesn't sound like the kind of thing to trigger a nostalgic reverie, but the other day one of them did just that.

Back in 1981, after my first day in my current office building, my secretary called me at home to say that the janitor was furious: He'd been stuck by a needle that came loose in one of the garbage bags.

We used to put capped needles in the trash!

Yes, there were needle breakers, little red plastic boxes that snipped off needles at the hub, but we didn't always use them; instead, we just screwed the needles into their plastic hubs before discarding them.

Then came AIDS and the Occupational Safety and Health Administration and sharps containers, but even those evolved. The first ones were crude affairs that let you poke inside to retrieve something and possibly get jabbed. Newer models eliminated that chance with one-way-valve openings. Change is troublesome but inevitable. We look for some of it, some we have thrust upon us, and the rest just sneaks in somehow.

Because most change is slow and incremental, it's hard to remember what things were like even a few years ago. We're always brought up short when we see a snapshot, an old TV sitcom, a movie like "Back to the Future." "Hey look, 'Bonanza!'" "I haven't seen a hand lawn mower since I was a kid." "How about those bell-bottoms?" "Look, Windows 98!" (That's for the younger set.)

My office past came blasting through recently in this exchange:

"Your skin cancer will need surgery, Mr. Mortimer. What hospital is your PCP with? I have to choose a specialist from the right referral circle."

"I have Blue Humdinger Supreme, Doctor. I can go anywhere."

"What?"

"I can go anywhere."

"You can go anywhere …?"

(I am running in slow motion through a green meadow filled with crimson wildflowers. Smiling models from nonsedating antihistamine ads are sitting at picnic tables, joyfully inhaling pollen. I can send my patients anywhere I want! It's a dream!)

Actually, it is. But once upon a time I could. Anybody could see me without referrals, and I didn't need an army of referral clerks. I could schedule a follow-up visit just because I wanted to. … I could write a prescription for any drug I felt like. …

We fixed typos with Wite-Out correction fluid. There was no voice mail or e-mail. Faxes had not been thought of. There wasn't any health insurance, and patients paid in chickens, if they paid at all.

You win some, you lose some.

We can't hide from change, but it may be best not to be the first kid on the block to adopt it, either. Let other people work out the bugs, and wait for the higher prices of early adoption to come down.

It's also a good idea to ignore the predators who are always ready to cash in on our fear of instability. They're the ones who send out those screaming flyers, "Give Us Lots of Money and We'll Protect You From the Latest Government Threat!" Better to wait for soberer voices, like those of our professional associations, to assess the situation and give guidance. The sky won't fall in the meantime.

Sometimes, change is so sensible it makes you wonder why it took so long to happen.

Back when I started, I sent pathology specimens to a lab at the derm department of my alma mater. They supplied me with little white cylinders containing a formalin bottle and path slip. Printed on the cylinder were the lab's address and a notice, "No postage necessary if mailed in the United States."

We sent specimens … by regular mail! (Online tracking was not available.)

"Dr. Rockoff, do I have melanoma or not?"

"Hello, lab, do you have the biopsy on Mr. Mortimer? … What do you mean, 'Who is Mr. Mortimer?'"

Yes, things like that really happened. Sometimes the missing cylinder eventually showed up, many palpitations later.

At some point in the early 1980s, some labs started offering courier service. Soon, all the rest followed suit.

See? At least in some respects, these are the good old days.

A jammed sharps container doesn't sound like the kind of thing to trigger a nostalgic reverie, but the other day one of them did just that.

Back in 1981, after my first day in my current office building, my secretary called me at home to say that the janitor was furious: He'd been stuck by a needle that came loose in one of the garbage bags.

We used to put capped needles in the trash!

Yes, there were needle breakers, little red plastic boxes that snipped off needles at the hub, but we didn't always use them; instead, we just screwed the needles into their plastic hubs before discarding them.

Then came AIDS and the Occupational Safety and Health Administration and sharps containers, but even those evolved. The first ones were crude affairs that let you poke inside to retrieve something and possibly get jabbed. Newer models eliminated that chance with one-way-valve openings. Change is troublesome but inevitable. We look for some of it, some we have thrust upon us, and the rest just sneaks in somehow.

Because most change is slow and incremental, it's hard to remember what things were like even a few years ago. We're always brought up short when we see a snapshot, an old TV sitcom, a movie like "Back to the Future." "Hey look, 'Bonanza!'" "I haven't seen a hand lawn mower since I was a kid." "How about those bell-bottoms?" "Look, Windows 98!" (That's for the younger set.)

My office past came blasting through recently in this exchange:

"Your skin cancer will need surgery, Mr. Mortimer. What hospital is your PCP with? I have to choose a specialist from the right referral circle."

"I have Blue Humdinger Supreme, Doctor. I can go anywhere."

"What?"

"I can go anywhere."

"You can go anywhere …?"

(I am running in slow motion through a green meadow filled with crimson wildflowers. Smiling models from nonsedating antihistamine ads are sitting at picnic tables, joyfully inhaling pollen. I can send my patients anywhere I want! It's a dream!)

Actually, it is. But once upon a time I could. Anybody could see me without referrals, and I didn't need an army of referral clerks. I could schedule a follow-up visit just because I wanted to. … I could write a prescription for any drug I felt like. …

We fixed typos with Wite-Out correction fluid. There was no voice mail or e-mail. Faxes had not been thought of. There wasn't any health insurance, and patients paid in chickens, if they paid at all.

You win some, you lose some.

We can't hide from change, but it may be best not to be the first kid on the block to adopt it, either. Let other people work out the bugs, and wait for the higher prices of early adoption to come down.

It's also a good idea to ignore the predators who are always ready to cash in on our fear of instability. They're the ones who send out those screaming flyers, "Give Us Lots of Money and We'll Protect You From the Latest Government Threat!" Better to wait for soberer voices, like those of our professional associations, to assess the situation and give guidance. The sky won't fall in the meantime.

Sometimes, change is so sensible it makes you wonder why it took so long to happen.

Back when I started, I sent pathology specimens to a lab at the derm department of my alma mater. They supplied me with little white cylinders containing a formalin bottle and path slip. Printed on the cylinder were the lab's address and a notice, "No postage necessary if mailed in the United States."

We sent specimens … by regular mail! (Online tracking was not available.)

"Dr. Rockoff, do I have melanoma or not?"

"Hello, lab, do you have the biopsy on Mr. Mortimer? … What do you mean, 'Who is Mr. Mortimer?'"

Yes, things like that really happened. Sometimes the missing cylinder eventually showed up, many palpitations later.

At some point in the early 1980s, some labs started offering courier service. Soon, all the rest followed suit.

See? At least in some respects, these are the good old days.

A jammed sharps container doesn't sound like the kind of thing to trigger a nostalgic reverie, but the other day one of them did just that.

Back in 1981, after my first day in my current office building, my secretary called me at home to say that the janitor was furious: He'd been stuck by a needle that came loose in one of the garbage bags.

We used to put capped needles in the trash!

Yes, there were needle breakers, little red plastic boxes that snipped off needles at the hub, but we didn't always use them; instead, we just screwed the needles into their plastic hubs before discarding them.

Then came AIDS and the Occupational Safety and Health Administration and sharps containers, but even those evolved. The first ones were crude affairs that let you poke inside to retrieve something and possibly get jabbed. Newer models eliminated that chance with one-way-valve openings. Change is troublesome but inevitable. We look for some of it, some we have thrust upon us, and the rest just sneaks in somehow.

Because most change is slow and incremental, it's hard to remember what things were like even a few years ago. We're always brought up short when we see a snapshot, an old TV sitcom, a movie like "Back to the Future." "Hey look, 'Bonanza!'" "I haven't seen a hand lawn mower since I was a kid." "How about those bell-bottoms?" "Look, Windows 98!" (That's for the younger set.)

My office past came blasting through recently in this exchange:

"Your skin cancer will need surgery, Mr. Mortimer. What hospital is your PCP with? I have to choose a specialist from the right referral circle."

"I have Blue Humdinger Supreme, Doctor. I can go anywhere."

"What?"

"I can go anywhere."

"You can go anywhere …?"

(I am running in slow motion through a green meadow filled with crimson wildflowers. Smiling models from nonsedating antihistamine ads are sitting at picnic tables, joyfully inhaling pollen. I can send my patients anywhere I want! It's a dream!)

Actually, it is. But once upon a time I could. Anybody could see me without referrals, and I didn't need an army of referral clerks. I could schedule a follow-up visit just because I wanted to. … I could write a prescription for any drug I felt like. …

We fixed typos with Wite-Out correction fluid. There was no voice mail or e-mail. Faxes had not been thought of. There wasn't any health insurance, and patients paid in chickens, if they paid at all.

You win some, you lose some.

We can't hide from change, but it may be best not to be the first kid on the block to adopt it, either. Let other people work out the bugs, and wait for the higher prices of early adoption to come down.

It's also a good idea to ignore the predators who are always ready to cash in on our fear of instability. They're the ones who send out those screaming flyers, "Give Us Lots of Money and We'll Protect You From the Latest Government Threat!" Better to wait for soberer voices, like those of our professional associations, to assess the situation and give guidance. The sky won't fall in the meantime.

Sometimes, change is so sensible it makes you wonder why it took so long to happen.

Back when I started, I sent pathology specimens to a lab at the derm department of my alma mater. They supplied me with little white cylinders containing a formalin bottle and path slip. Printed on the cylinder were the lab's address and a notice, "No postage necessary if mailed in the United States."

We sent specimens … by regular mail! (Online tracking was not available.)

"Dr. Rockoff, do I have melanoma or not?"

"Hello, lab, do you have the biopsy on Mr. Mortimer? … What do you mean, 'Who is Mr. Mortimer?'"

Yes, things like that really happened. Sometimes the missing cylinder eventually showed up, many palpitations later.

At some point in the early 1980s, some labs started offering courier service. Soon, all the rest followed suit.

See? At least in some respects, these are the good old days.