Under My Skin

How do you treat a patient who doesn’t want to be treated?

It depends. If the problem is acne or a wart, then it’s all right to let it go.

Harriet, however, has HIV. And a facial basal cell carcinoma.

Now what?

Perhaps it still depends.

After showing me a red spot on her right cheek, Harriet put me on notice right away. “I don’t believe in unnecessary treatments,” she said.

I asked her what she meant.

“I’ve been HIV positive since the mid-1980s,” she said. “Last year, my doctor wanted to pump me full of those poisons. So I changed doctors.”

“What does your new doctor think?” I asked.

“My T-cell counts aren’t very good. He also thinks I should take those medicines, but I don’t see him much.

“I went to another dermatologist about a different problem. He got very angry at me, because I had called in advance to ask not to be seen by a resident. They told me that would be OK, but the resident showed up anyway. When the doctor also came in and I tried to explain, he threw me out of the clinic.”

By now, I’d gotten the picture: Harriet has her own ideas about things and is not about to take advice with which she doesn’t agree. What makes Harriet different is not that she ignores medical advice – people do that all the time – but that she comes right out and says so to the doctor’s face. Others wait till they get home.

So what do you do when a patient shows that he or she is ready to look you in the eye and turn you down flat?

One response is to leave the room in a huff. After all, who’s the expert here, and who’s trying to help whom?

That reaction is understandable, but if the doctor walks out, who is being helped? The patient, or the doctor?

There is, of course, another approach, which is to suppress professional ego considerations and ask:

1. What are the actual medical stakes? What is the worst that could happen if the patient refuses treatment?

2. What realistic options, if any, are there to change the patient’s mind?

3. Why is the patient behaving that way, anyway?

In Harriet’s case, what are the medical stakes? I am no HIV specialist, but how many patients who seroconverted in the 1980s are still around to consider their options? (Other such patients have told me their doctors really don’t understand how patients like them survived.) If Harriet is sexually inactive and does not try to donate blood, how sure are we that she isn’t better off doing nothing?

Besides, what other options are there to change her mind?

Before turning to my third question, I have to plan what to do if – when – the biopsy confirms my clinical diagnosis of basal cell. I will inform Harriet, and recommend Mohs surgery. Suppose she refuses and wants a lesser procedure, or no surgery at all. What next?

This happens. If the patient is elderly, and the lesion is not near a strategic organ, such as the eye, it may be acceptable just to watch the lesion. Some basal cells grow fast, others barely grow at all. If Harriet decides to do nothing, I could explain my preference – surgery – and her risks – lesion growth and bigger surgery later – and insist on seeing her every 2 months.

Which brings us to our third question: Why would Harriet act this way?

Two possibilities occur to me. The first is fear. Scared people often act aggressively. Calmed down, they relent.

The second is that Harriet is what the English call bloody minded; in other words, deliberately uncooperative.

Battling with the bloody minded is not helpful for anybody.

Negotiating with difficult people is much less gratifying than giving advice and being respectfully thanked for our efforts and expertise.

Sometimes, though, the best we can do is to swallow our professional pride, try to defuse what fear we can, and show that we will push only as hard as clinical risk truly justifies. This is not always easy to do but is often worth the effort. It may certainly be the best available alternative.

Harriet’s biopsy showed a basal cell. She readily agreed to surgery.

You never know.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].

How do you treat a patient who doesn’t want to be treated?

It depends. If the problem is acne or a wart, then it’s all right to let it go.

Harriet, however, has HIV. And a facial basal cell carcinoma.

Now what?

Perhaps it still depends.

After showing me a red spot on her right cheek, Harriet put me on notice right away. “I don’t believe in unnecessary treatments,” she said.

I asked her what she meant.

“I’ve been HIV positive since the mid-1980s,” she said. “Last year, my doctor wanted to pump me full of those poisons. So I changed doctors.”

“What does your new doctor think?” I asked.

“My T-cell counts aren’t very good. He also thinks I should take those medicines, but I don’t see him much.

“I went to another dermatologist about a different problem. He got very angry at me, because I had called in advance to ask not to be seen by a resident. They told me that would be OK, but the resident showed up anyway. When the doctor also came in and I tried to explain, he threw me out of the clinic.”

By now, I’d gotten the picture: Harriet has her own ideas about things and is not about to take advice with which she doesn’t agree. What makes Harriet different is not that she ignores medical advice – people do that all the time – but that she comes right out and says so to the doctor’s face. Others wait till they get home.

So what do you do when a patient shows that he or she is ready to look you in the eye and turn you down flat?

One response is to leave the room in a huff. After all, who’s the expert here, and who’s trying to help whom?

That reaction is understandable, but if the doctor walks out, who is being helped? The patient, or the doctor?

There is, of course, another approach, which is to suppress professional ego considerations and ask:

1. What are the actual medical stakes? What is the worst that could happen if the patient refuses treatment?

2. What realistic options, if any, are there to change the patient’s mind?

3. Why is the patient behaving that way, anyway?

In Harriet’s case, what are the medical stakes? I am no HIV specialist, but how many patients who seroconverted in the 1980s are still around to consider their options? (Other such patients have told me their doctors really don’t understand how patients like them survived.) If Harriet is sexually inactive and does not try to donate blood, how sure are we that she isn’t better off doing nothing?

Besides, what other options are there to change her mind?

Before turning to my third question, I have to plan what to do if – when – the biopsy confirms my clinical diagnosis of basal cell. I will inform Harriet, and recommend Mohs surgery. Suppose she refuses and wants a lesser procedure, or no surgery at all. What next?

This happens. If the patient is elderly, and the lesion is not near a strategic organ, such as the eye, it may be acceptable just to watch the lesion. Some basal cells grow fast, others barely grow at all. If Harriet decides to do nothing, I could explain my preference – surgery – and her risks – lesion growth and bigger surgery later – and insist on seeing her every 2 months.

Which brings us to our third question: Why would Harriet act this way?

Two possibilities occur to me. The first is fear. Scared people often act aggressively. Calmed down, they relent.

The second is that Harriet is what the English call bloody minded; in other words, deliberately uncooperative.

Battling with the bloody minded is not helpful for anybody.

Negotiating with difficult people is much less gratifying than giving advice and being respectfully thanked for our efforts and expertise.

Sometimes, though, the best we can do is to swallow our professional pride, try to defuse what fear we can, and show that we will push only as hard as clinical risk truly justifies. This is not always easy to do but is often worth the effort. It may certainly be the best available alternative.

Harriet’s biopsy showed a basal cell. She readily agreed to surgery.

You never know.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].

How do you treat a patient who doesn’t want to be treated?

It depends. If the problem is acne or a wart, then it’s all right to let it go.

Harriet, however, has HIV. And a facial basal cell carcinoma.

Now what?

Perhaps it still depends.

After showing me a red spot on her right cheek, Harriet put me on notice right away. “I don’t believe in unnecessary treatments,” she said.

I asked her what she meant.

“I’ve been HIV positive since the mid-1980s,” she said. “Last year, my doctor wanted to pump me full of those poisons. So I changed doctors.”

“What does your new doctor think?” I asked.

“My T-cell counts aren’t very good. He also thinks I should take those medicines, but I don’t see him much.

“I went to another dermatologist about a different problem. He got very angry at me, because I had called in advance to ask not to be seen by a resident. They told me that would be OK, but the resident showed up anyway. When the doctor also came in and I tried to explain, he threw me out of the clinic.”

By now, I’d gotten the picture: Harriet has her own ideas about things and is not about to take advice with which she doesn’t agree. What makes Harriet different is not that she ignores medical advice – people do that all the time – but that she comes right out and says so to the doctor’s face. Others wait till they get home.

So what do you do when a patient shows that he or she is ready to look you in the eye and turn you down flat?

One response is to leave the room in a huff. After all, who’s the expert here, and who’s trying to help whom?

That reaction is understandable, but if the doctor walks out, who is being helped? The patient, or the doctor?

There is, of course, another approach, which is to suppress professional ego considerations and ask:

1. What are the actual medical stakes? What is the worst that could happen if the patient refuses treatment?

2. What realistic options, if any, are there to change the patient’s mind?

3. Why is the patient behaving that way, anyway?

In Harriet’s case, what are the medical stakes? I am no HIV specialist, but how many patients who seroconverted in the 1980s are still around to consider their options? (Other such patients have told me their doctors really don’t understand how patients like them survived.) If Harriet is sexually inactive and does not try to donate blood, how sure are we that she isn’t better off doing nothing?

Besides, what other options are there to change her mind?

Before turning to my third question, I have to plan what to do if – when – the biopsy confirms my clinical diagnosis of basal cell. I will inform Harriet, and recommend Mohs surgery. Suppose she refuses and wants a lesser procedure, or no surgery at all. What next?

This happens. If the patient is elderly, and the lesion is not near a strategic organ, such as the eye, it may be acceptable just to watch the lesion. Some basal cells grow fast, others barely grow at all. If Harriet decides to do nothing, I could explain my preference – surgery – and her risks – lesion growth and bigger surgery later – and insist on seeing her every 2 months.

Which brings us to our third question: Why would Harriet act this way?

Two possibilities occur to me. The first is fear. Scared people often act aggressively. Calmed down, they relent.

The second is that Harriet is what the English call bloody minded; in other words, deliberately uncooperative.

Battling with the bloody minded is not helpful for anybody.

Negotiating with difficult people is much less gratifying than giving advice and being respectfully thanked for our efforts and expertise.

Sometimes, though, the best we can do is to swallow our professional pride, try to defuse what fear we can, and show that we will push only as hard as clinical risk truly justifies. This is not always easy to do but is often worth the effort. It may certainly be the best available alternative.

Harriet’s biopsy showed a basal cell. She readily agreed to surgery.

You never know.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].

When patients say they had “a reaction” to some treatment, they often don’t mean what we would call allergy or even intolerance. This doesn’t make their reluctance – or refusal – to consider what we suggest any less insistent.

I’ve lost track, for insistence, of the number of patients who called 2 days after I prescribed clindamycin lotion to complain that it “dried me out completely.”

When a customer in a cosmetic store or pharmacy returns a skin care cream because of that kind of “reaction,” the store takes it back, no questions asked. This is not just good business practice; in that context, both the customer and the salesperson use the word “reaction” the way laymen do, not the way doctors do.

If you doubt a reaction is real and say so, however gently, the response you may get is, “That may be true, Doctor, but my body is sensitive. I get strange reactions.”

Like most everyone else in practice, I use negotiating tactics, such as: “Stop the cream for 3 days, then try it again, but just in one spot in front of your left ear.”

Some patients agree to try this. Mostly, nothing happens, they resume the medication, and life goes on. For fearful people, we have to use something else. Sometimes patients and I run through a succession of options, each of which produces an inscrutable “reaction.”

As the years pass, I’ve gotten better at gauging the range of true reactions to medications. At the same time, the list of perplexing things patients complain about gets longer all the time. Lately, there’s been a run of them:

• The woman who used low-strength tretinoin cream all of twice and stopped 2 weeks ago who insisted that “my face is still all dried out.” I assured her that 2 days of tretinoin cannot damage the skin forever, but she remains unconvinced.

• The man who says that putting tretinoin on his face “made me dry out all over.”

• The mother who said her daughter stopped my steroid cream because “every time we used it, her tongue broke out in blisters.”

•  The middle-aged woman who claimed, “I can’t take minocycline because it changed the color of my teeth and my eyes.”

• The young woman who puts clindamycin pads only on her right cheek, where she still has pimples, but not on the left, “because it makes the pimples go away on the cheek that has them, but on the other side it makes pimples come out.”

When I hear complaints like these, I just sigh and make a lateral move.

But sometimes I run out of lateral moves. The other month a woman told me that doxycycline made her “tired.” We tried minocycline, but that made her “irritable.” “My body is prone to strange reactions that no one else gets,” she explained. Then she asked for a third option.

“I honestly don’t know what to suggest,” I apologized. “Because your body reacts in ways that other people don’t, I can’t predict what some other treatment will do to you, even if it hasn’t done it to anyone else.”

She asked for her records, to get another opinion. I happily complied.

Speaking of weird “reactions,” there are of course the ones listed on e-scribing programs. Here are a couple:

• Hydrocortisone valerate has been associated with WARTS. (Capitalized)

• Hydrocortisone valerate has been associated with tinea cruris.

Make any sense to you? Me neither.

I end with a call I got the other day from a pharmacist. This concerned a patient for whom I had prescribed oral doxycycline and topical tretinoin. The message was, “Please call regarding drug interaction.”

When I got through, I politely asked the nature of this interaction. The pharmacist said she didn’t know exactly, but would look into it and fax me the details.

Half an hour later I got a sheet explaining the there is an increased risk of pseudotumor cerebri when patients take both oral tretinoin and oral tetracyclines.

That is correct: Not isotretinoin. Oral tretinoin. Used any oral tretinoin lately?

At any rate, the helpful pharmacist wrote at the bottom, “This interaction is flagged by several insurers for topical tretinoin too.”

Thank heavens for computer-generated warnings. Whatever would we do without them?

Besides, it’s nice to know that even after all these years, I can still react myself, with surprise.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].

When patients say they had “a reaction” to some treatment, they often don’t mean what we would call allergy or even intolerance. This doesn’t make their reluctance – or refusal – to consider what we suggest any less insistent.

I’ve lost track, for insistence, of the number of patients who called 2 days after I prescribed clindamycin lotion to complain that it “dried me out completely.”

When a customer in a cosmetic store or pharmacy returns a skin care cream because of that kind of “reaction,” the store takes it back, no questions asked. This is not just good business practice; in that context, both the customer and the salesperson use the word “reaction” the way laymen do, not the way doctors do.

If you doubt a reaction is real and say so, however gently, the response you may get is, “That may be true, Doctor, but my body is sensitive. I get strange reactions.”

Like most everyone else in practice, I use negotiating tactics, such as: “Stop the cream for 3 days, then try it again, but just in one spot in front of your left ear.”

Some patients agree to try this. Mostly, nothing happens, they resume the medication, and life goes on. For fearful people, we have to use something else. Sometimes patients and I run through a succession of options, each of which produces an inscrutable “reaction.”

As the years pass, I’ve gotten better at gauging the range of true reactions to medications. At the same time, the list of perplexing things patients complain about gets longer all the time. Lately, there’s been a run of them:

• The woman who used low-strength tretinoin cream all of twice and stopped 2 weeks ago who insisted that “my face is still all dried out.” I assured her that 2 days of tretinoin cannot damage the skin forever, but she remains unconvinced.

• The man who says that putting tretinoin on his face “made me dry out all over.”

• The mother who said her daughter stopped my steroid cream because “every time we used it, her tongue broke out in blisters.”

•  The middle-aged woman who claimed, “I can’t take minocycline because it changed the color of my teeth and my eyes.”

• The young woman who puts clindamycin pads only on her right cheek, where she still has pimples, but not on the left, “because it makes the pimples go away on the cheek that has them, but on the other side it makes pimples come out.”

When I hear complaints like these, I just sigh and make a lateral move.

But sometimes I run out of lateral moves. The other month a woman told me that doxycycline made her “tired.” We tried minocycline, but that made her “irritable.” “My body is prone to strange reactions that no one else gets,” she explained. Then she asked for a third option.

“I honestly don’t know what to suggest,” I apologized. “Because your body reacts in ways that other people don’t, I can’t predict what some other treatment will do to you, even if it hasn’t done it to anyone else.”

She asked for her records, to get another opinion. I happily complied.

Speaking of weird “reactions,” there are of course the ones listed on e-scribing programs. Here are a couple:

• Hydrocortisone valerate has been associated with WARTS. (Capitalized)

• Hydrocortisone valerate has been associated with tinea cruris.

Make any sense to you? Me neither.

I end with a call I got the other day from a pharmacist. This concerned a patient for whom I had prescribed oral doxycycline and topical tretinoin. The message was, “Please call regarding drug interaction.”

When I got through, I politely asked the nature of this interaction. The pharmacist said she didn’t know exactly, but would look into it and fax me the details.

Half an hour later I got a sheet explaining the there is an increased risk of pseudotumor cerebri when patients take both oral tretinoin and oral tetracyclines.

That is correct: Not isotretinoin. Oral tretinoin. Used any oral tretinoin lately?

At any rate, the helpful pharmacist wrote at the bottom, “This interaction is flagged by several insurers for topical tretinoin too.”

Thank heavens for computer-generated warnings. Whatever would we do without them?

Besides, it’s nice to know that even after all these years, I can still react myself, with surprise.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].

When patients say they had “a reaction” to some treatment, they often don’t mean what we would call allergy or even intolerance. This doesn’t make their reluctance – or refusal – to consider what we suggest any less insistent.

I’ve lost track, for insistence, of the number of patients who called 2 days after I prescribed clindamycin lotion to complain that it “dried me out completely.”

When a customer in a cosmetic store or pharmacy returns a skin care cream because of that kind of “reaction,” the store takes it back, no questions asked. This is not just good business practice; in that context, both the customer and the salesperson use the word “reaction” the way laymen do, not the way doctors do.

If you doubt a reaction is real and say so, however gently, the response you may get is, “That may be true, Doctor, but my body is sensitive. I get strange reactions.”

Like most everyone else in practice, I use negotiating tactics, such as: “Stop the cream for 3 days, then try it again, but just in one spot in front of your left ear.”

Some patients agree to try this. Mostly, nothing happens, they resume the medication, and life goes on. For fearful people, we have to use something else. Sometimes patients and I run through a succession of options, each of which produces an inscrutable “reaction.”

As the years pass, I’ve gotten better at gauging the range of true reactions to medications. At the same time, the list of perplexing things patients complain about gets longer all the time. Lately, there’s been a run of them:

• The woman who used low-strength tretinoin cream all of twice and stopped 2 weeks ago who insisted that “my face is still all dried out.” I assured her that 2 days of tretinoin cannot damage the skin forever, but she remains unconvinced.

• The man who says that putting tretinoin on his face “made me dry out all over.”

• The mother who said her daughter stopped my steroid cream because “every time we used it, her tongue broke out in blisters.”

•  The middle-aged woman who claimed, “I can’t take minocycline because it changed the color of my teeth and my eyes.”

• The young woman who puts clindamycin pads only on her right cheek, where she still has pimples, but not on the left, “because it makes the pimples go away on the cheek that has them, but on the other side it makes pimples come out.”

When I hear complaints like these, I just sigh and make a lateral move.

But sometimes I run out of lateral moves. The other month a woman told me that doxycycline made her “tired.” We tried minocycline, but that made her “irritable.” “My body is prone to strange reactions that no one else gets,” she explained. Then she asked for a third option.

“I honestly don’t know what to suggest,” I apologized. “Because your body reacts in ways that other people don’t, I can’t predict what some other treatment will do to you, even if it hasn’t done it to anyone else.”

She asked for her records, to get another opinion. I happily complied.

Speaking of weird “reactions,” there are of course the ones listed on e-scribing programs. Here are a couple:

• Hydrocortisone valerate has been associated with WARTS. (Capitalized)

• Hydrocortisone valerate has been associated with tinea cruris.

Make any sense to you? Me neither.

I end with a call I got the other day from a pharmacist. This concerned a patient for whom I had prescribed oral doxycycline and topical tretinoin. The message was, “Please call regarding drug interaction.”

When I got through, I politely asked the nature of this interaction. The pharmacist said she didn’t know exactly, but would look into it and fax me the details.

Half an hour later I got a sheet explaining the there is an increased risk of pseudotumor cerebri when patients take both oral tretinoin and oral tetracyclines.

That is correct: Not isotretinoin. Oral tretinoin. Used any oral tretinoin lately?

At any rate, the helpful pharmacist wrote at the bottom, “This interaction is flagged by several insurers for topical tretinoin too.”

Thank heavens for computer-generated warnings. Whatever would we do without them?

Besides, it’s nice to know that even after all these years, I can still react myself, with surprise.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].

Early in my career, an attorney asked me to review a malpractice case. “The question,” he said, “is whether liquid nitrogen is the standard of care for treating warts.”

Come again?

A young woman had visited an academic center, where a physician froze her warts. These blistered and turned purple. Alarmed, she went to an ER, where doctors admitted her for cellulitis and gave her intravenous antibiotics for several days.

I later submitted an essay based on this case to my malpractice insurer’s Risk Management Contest, in which I called for better communication between treating doctors and those who follow up. I placed second and got a check from my malpractice insurer. How cool is that?

I hadn’t thought about that case in years, until last month. Earvin is a late-middle-aged gent with psoriasis on his elbows and liver spots on his chest. He asked me to freeze them, as I had done before.

After lunch 2 days later, my secretary buzzed me. “The man on the phone is very unhappy,” she said. “He says he called this morning and no one called back. He says if he doesn’t hear from you, his next call will be to his attorney.”

I phoned Earvin. My apology for not having gotten the message before was met with frigid hostility. “That’s unconscionable,” he said.

“My skin swelled up like a balloon,” he told me. “I know what to expect with freezing, and this never happened before. I think this time you froze me with a heavy hand. When I didn’t hear from you, I went to an urgent care clinic down the street. They said it was infected and prescribed an antibiotic ointment. I had to wait an hour, and the ointment cost $49.”

I held my breath. “Actually,” I said, “I don’t think it’s infected.”

“They said it was infected,” said Earvin. “It is swollen. I’m afraid it is going to scar. The cream cost $49.”

Straining to keep my voice even, I replied, “Would you like me to have a look at it?”

“I live too far,” he said. “I don’t have a ride. Maybe I will come tomorrow if someone can take me.”

Later that day I called him back. “I live the next town over from you,” I said. “I will stop by on my way home.” He agreed, and told me the color of his house.

Earvin let me in looking less angry than fearful. One glance at his chest told me what I needed to know: There was no infection. His skin looked like what skin looks like after it’s been frozen. Other treated areas – the ones Earvin wasn’t worried about – looked the same to me, though clearly not to him. “This one was worse,” he said. “It’s gone down since this morning.”

After examining Earvin with my cell phone flashlight, I sat down across from him. “Let me be clear,” I said. “You are not infected. Some areas frozen at the same time in the same way blister more briskly than others. In the end they heal fine, and so will yours. You’re not going to scar.”

Earvin relaxed a little. “I was afraid I’d done something I didn’t need to. My mother had skin cancer on her chest, not far from where this one is. My skin was discolored and swollen. The doctor at urgent care said it was infected.” There was a pause, as Earvin slumped in his chair. “I feel better,” he allowed.

There it was, the whole package – thinking that was full of hopelessly muddled categories. Infection? Scarring? Skin cancer? Yes to all? And there was moral anxiety – disappointment in himself for doing something needless and now having to pay the price – as well as anger at me as the instrument of retribution. Who knows what else? There were so many strands, hopelessly coiled, impossible to disentangle.

And all wrapped up in elemental terror. What have I done? What has he done?

Earvin did not need treatment. He needed a hug. Metaphorically, that is what I gave him.

So much angst, so much anger, so much fear, so little time. To be frank, it gets tiring.

People like to quote the philosopher George Santayana. He said that those who cannot remember the past are condemned to repeat it.

I like to paraphrase the even greater philosopher Bill Murray of “Groundhog Day”: Those who do remember the past are condemned to repeat it anyway.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Early in my career, an attorney asked me to review a malpractice case. “The question,” he said, “is whether liquid nitrogen is the standard of care for treating warts.”

Come again?

A young woman had visited an academic center, where a physician froze her warts. These blistered and turned purple. Alarmed, she went to an ER, where doctors admitted her for cellulitis and gave her intravenous antibiotics for several days.

I later submitted an essay based on this case to my malpractice insurer’s Risk Management Contest, in which I called for better communication between treating doctors and those who follow up. I placed second and got a check from my malpractice insurer. How cool is that?

I hadn’t thought about that case in years, until last month. Earvin is a late-middle-aged gent with psoriasis on his elbows and liver spots on his chest. He asked me to freeze them, as I had done before.

After lunch 2 days later, my secretary buzzed me. “The man on the phone is very unhappy,” she said. “He says he called this morning and no one called back. He says if he doesn’t hear from you, his next call will be to his attorney.”

I phoned Earvin. My apology for not having gotten the message before was met with frigid hostility. “That’s unconscionable,” he said.

“My skin swelled up like a balloon,” he told me. “I know what to expect with freezing, and this never happened before. I think this time you froze me with a heavy hand. When I didn’t hear from you, I went to an urgent care clinic down the street. They said it was infected and prescribed an antibiotic ointment. I had to wait an hour, and the ointment cost $49.”

I held my breath. “Actually,” I said, “I don’t think it’s infected.”

“They said it was infected,” said Earvin. “It is swollen. I’m afraid it is going to scar. The cream cost $49.”

Straining to keep my voice even, I replied, “Would you like me to have a look at it?”

“I live too far,” he said. “I don’t have a ride. Maybe I will come tomorrow if someone can take me.”

Later that day I called him back. “I live the next town over from you,” I said. “I will stop by on my way home.” He agreed, and told me the color of his house.

Earvin let me in looking less angry than fearful. One glance at his chest told me what I needed to know: There was no infection. His skin looked like what skin looks like after it’s been frozen. Other treated areas – the ones Earvin wasn’t worried about – looked the same to me, though clearly not to him. “This one was worse,” he said. “It’s gone down since this morning.”

After examining Earvin with my cell phone flashlight, I sat down across from him. “Let me be clear,” I said. “You are not infected. Some areas frozen at the same time in the same way blister more briskly than others. In the end they heal fine, and so will yours. You’re not going to scar.”

Earvin relaxed a little. “I was afraid I’d done something I didn’t need to. My mother had skin cancer on her chest, not far from where this one is. My skin was discolored and swollen. The doctor at urgent care said it was infected.” There was a pause, as Earvin slumped in his chair. “I feel better,” he allowed.

There it was, the whole package – thinking that was full of hopelessly muddled categories. Infection? Scarring? Skin cancer? Yes to all? And there was moral anxiety – disappointment in himself for doing something needless and now having to pay the price – as well as anger at me as the instrument of retribution. Who knows what else? There were so many strands, hopelessly coiled, impossible to disentangle.

And all wrapped up in elemental terror. What have I done? What has he done?

Earvin did not need treatment. He needed a hug. Metaphorically, that is what I gave him.

So much angst, so much anger, so much fear, so little time. To be frank, it gets tiring.

People like to quote the philosopher George Santayana. He said that those who cannot remember the past are condemned to repeat it.

I like to paraphrase the even greater philosopher Bill Murray of “Groundhog Day”: Those who do remember the past are condemned to repeat it anyway.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Early in my career, an attorney asked me to review a malpractice case. “The question,” he said, “is whether liquid nitrogen is the standard of care for treating warts.”

Come again?

A young woman had visited an academic center, where a physician froze her warts. These blistered and turned purple. Alarmed, she went to an ER, where doctors admitted her for cellulitis and gave her intravenous antibiotics for several days.

I later submitted an essay based on this case to my malpractice insurer’s Risk Management Contest, in which I called for better communication between treating doctors and those who follow up. I placed second and got a check from my malpractice insurer. How cool is that?

I hadn’t thought about that case in years, until last month. Earvin is a late-middle-aged gent with psoriasis on his elbows and liver spots on his chest. He asked me to freeze them, as I had done before.

After lunch 2 days later, my secretary buzzed me. “The man on the phone is very unhappy,” she said. “He says he called this morning and no one called back. He says if he doesn’t hear from you, his next call will be to his attorney.”

I phoned Earvin. My apology for not having gotten the message before was met with frigid hostility. “That’s unconscionable,” he said.

“My skin swelled up like a balloon,” he told me. “I know what to expect with freezing, and this never happened before. I think this time you froze me with a heavy hand. When I didn’t hear from you, I went to an urgent care clinic down the street. They said it was infected and prescribed an antibiotic ointment. I had to wait an hour, and the ointment cost $49.”

I held my breath. “Actually,” I said, “I don’t think it’s infected.”

“They said it was infected,” said Earvin. “It is swollen. I’m afraid it is going to scar. The cream cost $49.”

Straining to keep my voice even, I replied, “Would you like me to have a look at it?”

“I live too far,” he said. “I don’t have a ride. Maybe I will come tomorrow if someone can take me.”

Later that day I called him back. “I live the next town over from you,” I said. “I will stop by on my way home.” He agreed, and told me the color of his house.

Earvin let me in looking less angry than fearful. One glance at his chest told me what I needed to know: There was no infection. His skin looked like what skin looks like after it’s been frozen. Other treated areas – the ones Earvin wasn’t worried about – looked the same to me, though clearly not to him. “This one was worse,” he said. “It’s gone down since this morning.”

After examining Earvin with my cell phone flashlight, I sat down across from him. “Let me be clear,” I said. “You are not infected. Some areas frozen at the same time in the same way blister more briskly than others. In the end they heal fine, and so will yours. You’re not going to scar.”

Earvin relaxed a little. “I was afraid I’d done something I didn’t need to. My mother had skin cancer on her chest, not far from where this one is. My skin was discolored and swollen. The doctor at urgent care said it was infected.” There was a pause, as Earvin slumped in his chair. “I feel better,” he allowed.

There it was, the whole package – thinking that was full of hopelessly muddled categories. Infection? Scarring? Skin cancer? Yes to all? And there was moral anxiety – disappointment in himself for doing something needless and now having to pay the price – as well as anger at me as the instrument of retribution. Who knows what else? There were so many strands, hopelessly coiled, impossible to disentangle.

And all wrapped up in elemental terror. What have I done? What has he done?

Earvin did not need treatment. He needed a hug. Metaphorically, that is what I gave him.

So much angst, so much anger, so much fear, so little time. To be frank, it gets tiring.

People like to quote the philosopher George Santayana. He said that those who cannot remember the past are condemned to repeat it.

I like to paraphrase the even greater philosopher Bill Murray of “Groundhog Day”: Those who do remember the past are condemned to repeat it anyway.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Voice recognition software has come a long way. I tried it 15 years ago, but gave up in frustration. Recently, I took another look and found that technology has advanced a lot. Although I can now dictate fast and see the words pour out with impressive accuracy, there are still plenty of errors – some of them quite … interesting. Below is a case summary made up of examples from my growing collection of things the computer seems to have thought I said.

The moral: If you dictate with voice recognition software, proofread!

Chief Complaint

This 43-year-old woman presents with chief complaints of “facial and skin issues.”

Past Medical History

She reports that he has been engaged in a prolonged bottle with acne. It has lasted 18 months, urinary half. A previous physician prescribed an oral antibiotic, either doxycycline or minor cycling. She reports recurrent tachycardia on the forehead and cheeks. Although her outbreaks are not always hormonal, she sometimes gets worse around her. I said around her.! Her menstrual.!! Oh, never mind. It’s good that her name isn’t Cohen, because the computer hears that as :

She has scalp itch and here loss, and is convinced she has pediculosis capitis because of head Lausten chief found. There is a remote history of localized baldness, but not of alopecia universe Alice.

Though free of eczema in recent years, she recalls ataxic childhood.

She was recently exposed to chicken pox but did not contract Maricella. Her history of viral illnesses includes Molested contagiosum.

When she goes in the sun, she is not able to get a 10. She takes no narcotic analgesics, especially Oxyclean.

Occasional scaly rashes have been treated with both antifungal and antibiotic East creams, and sometimes with topical spheroids.

The patient has undergone various medical anesthetic procedures.

Personal and social history

The last 4 digits of her Social Security number are 1/6/09.

She is Director of Marketing for an appetizing agency. Her uncle is a scientist who won the No Bell Prize.

Hobbies: Skiing in Aspirin, Colorado. Competitive barbecue in dialysis, Texas.

Physical Examination

Eyes: There is a cystic lesion on the right I. This is a she’ll lazy on.

Face: Her breakouts are popular. The facial lesions are robbed because of Washington with vigor. Several are just above the nose on the club Ella. There is also sun damage: She has to saltwater keratoses on the 4 head.

Neck: Shotty notes. There is dark thickening typical of a cantholysis Neighbor can’t. There are firm lesions on the occipital scalp consistent with folliculitis Keloid Dallas. The redness on both sides of her neck represents Poikilokderma of survived.

Hands: Xerosis, aggravated by frequent hand washing with puerile. Nails demonstrate the partial separation of cholelithiasis.

Torso: There is a lichenoid rash that sometimes loses. This rash is all over and is very expensive. It is lichenoid and shows a violent color. She has many demented lesions. All are B9.

Upper extremities: There are four systolic keratoses on the vulvar forearm.

Lower extremities: There is a bleeding red lesion of recent onset on the left thigh. It is a high and Janet granuloma.

Groin: Her penile wart is not visible.

Assessment and plan

I will desiccate her high and Janet granuloma.

Will treat her losing rash with Burro solution soaks, followed by topical spheroids.

She was worried that she has precancerous cemented lesions, but I see no indication that she dies.

She will clean her hands less often, otherwise he will have Cirrhosis from Washington. She will moisturize with Aqua 4.

While outdoors, she will protect herself from the son.

For acne, recommended isotretinoin, enrolled patient in iPledge program. She cannot have a fasting blood test today, as she 8 this morning. He will obtain a pregnancy test, and I will confirm patient’s cuddling.

My staph will send a report of today’s visit to the patient’s Coronary Physician.

Dr. Rockoff practices dermatology in Brookline, Mass. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Voice recognition software has come a long way. I tried it 15 years ago, but gave up in frustration. Recently, I took another look and found that technology has advanced a lot. Although I can now dictate fast and see the words pour out with impressive accuracy, there are still plenty of errors – some of them quite … interesting. Below is a case summary made up of examples from my growing collection of things the computer seems to have thought I said.

The moral: If you dictate with voice recognition software, proofread!

Chief Complaint

This 43-year-old woman presents with chief complaints of “facial and skin issues.”

Past Medical History

She reports that he has been engaged in a prolonged bottle with acne. It has lasted 18 months, urinary half. A previous physician prescribed an oral antibiotic, either doxycycline or minor cycling. She reports recurrent tachycardia on the forehead and cheeks. Although her outbreaks are not always hormonal, she sometimes gets worse around her. I said around her.! Her menstrual.!! Oh, never mind. It’s good that her name isn’t Cohen, because the computer hears that as :

She has scalp itch and here loss, and is convinced she has pediculosis capitis because of head Lausten chief found. There is a remote history of localized baldness, but not of alopecia universe Alice.

Though free of eczema in recent years, she recalls ataxic childhood.

She was recently exposed to chicken pox but did not contract Maricella. Her history of viral illnesses includes Molested contagiosum.

When she goes in the sun, she is not able to get a 10. She takes no narcotic analgesics, especially Oxyclean.

Occasional scaly rashes have been treated with both antifungal and antibiotic East creams, and sometimes with topical spheroids.

The patient has undergone various medical anesthetic procedures.

Personal and social history

The last 4 digits of her Social Security number are 1/6/09.

She is Director of Marketing for an appetizing agency. Her uncle is a scientist who won the No Bell Prize.

Hobbies: Skiing in Aspirin, Colorado. Competitive barbecue in dialysis, Texas.

Physical Examination

Eyes: There is a cystic lesion on the right I. This is a she’ll lazy on.

Face: Her breakouts are popular. The facial lesions are robbed because of Washington with vigor. Several are just above the nose on the club Ella. There is also sun damage: She has to saltwater keratoses on the 4 head.

Neck: Shotty notes. There is dark thickening typical of a cantholysis Neighbor can’t. There are firm lesions on the occipital scalp consistent with folliculitis Keloid Dallas. The redness on both sides of her neck represents Poikilokderma of survived.

Hands: Xerosis, aggravated by frequent hand washing with puerile. Nails demonstrate the partial separation of cholelithiasis.

Torso: There is a lichenoid rash that sometimes loses. This rash is all over and is very expensive. It is lichenoid and shows a violent color. She has many demented lesions. All are B9.

Upper extremities: There are four systolic keratoses on the vulvar forearm.

Lower extremities: There is a bleeding red lesion of recent onset on the left thigh. It is a high and Janet granuloma.

Groin: Her penile wart is not visible.

Assessment and plan

I will desiccate her high and Janet granuloma.

Will treat her losing rash with Burro solution soaks, followed by topical spheroids.

She was worried that she has precancerous cemented lesions, but I see no indication that she dies.

She will clean her hands less often, otherwise he will have Cirrhosis from Washington. She will moisturize with Aqua 4.

While outdoors, she will protect herself from the son.

For acne, recommended isotretinoin, enrolled patient in iPledge program. She cannot have a fasting blood test today, as she 8 this morning. He will obtain a pregnancy test, and I will confirm patient’s cuddling.

My staph will send a report of today’s visit to the patient’s Coronary Physician.

Dr. Rockoff practices dermatology in Brookline, Mass. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Voice recognition software has come a long way. I tried it 15 years ago, but gave up in frustration. Recently, I took another look and found that technology has advanced a lot. Although I can now dictate fast and see the words pour out with impressive accuracy, there are still plenty of errors – some of them quite … interesting. Below is a case summary made up of examples from my growing collection of things the computer seems to have thought I said.

The moral: If you dictate with voice recognition software, proofread!

Chief Complaint

This 43-year-old woman presents with chief complaints of “facial and skin issues.”

Past Medical History

She reports that he has been engaged in a prolonged bottle with acne. It has lasted 18 months, urinary half. A previous physician prescribed an oral antibiotic, either doxycycline or minor cycling. She reports recurrent tachycardia on the forehead and cheeks. Although her outbreaks are not always hormonal, she sometimes gets worse around her. I said around her.! Her menstrual.!! Oh, never mind. It’s good that her name isn’t Cohen, because the computer hears that as :

She has scalp itch and here loss, and is convinced she has pediculosis capitis because of head Lausten chief found. There is a remote history of localized baldness, but not of alopecia universe Alice.

Though free of eczema in recent years, she recalls ataxic childhood.

She was recently exposed to chicken pox but did not contract Maricella. Her history of viral illnesses includes Molested contagiosum.

When she goes in the sun, she is not able to get a 10. She takes no narcotic analgesics, especially Oxyclean.

Occasional scaly rashes have been treated with both antifungal and antibiotic East creams, and sometimes with topical spheroids.

The patient has undergone various medical anesthetic procedures.

Personal and social history

The last 4 digits of her Social Security number are 1/6/09.

She is Director of Marketing for an appetizing agency. Her uncle is a scientist who won the No Bell Prize.

Hobbies: Skiing in Aspirin, Colorado. Competitive barbecue in dialysis, Texas.

Physical Examination

Eyes: There is a cystic lesion on the right I. This is a she’ll lazy on.

Face: Her breakouts are popular. The facial lesions are robbed because of Washington with vigor. Several are just above the nose on the club Ella. There is also sun damage: She has to saltwater keratoses on the 4 head.

Neck: Shotty notes. There is dark thickening typical of a cantholysis Neighbor can’t. There are firm lesions on the occipital scalp consistent with folliculitis Keloid Dallas. The redness on both sides of her neck represents Poikilokderma of survived.

Hands: Xerosis, aggravated by frequent hand washing with puerile. Nails demonstrate the partial separation of cholelithiasis.

Torso: There is a lichenoid rash that sometimes loses. This rash is all over and is very expensive. It is lichenoid and shows a violent color. She has many demented lesions. All are B9.

Upper extremities: There are four systolic keratoses on the vulvar forearm.

Lower extremities: There is a bleeding red lesion of recent onset on the left thigh. It is a high and Janet granuloma.

Groin: Her penile wart is not visible.

Assessment and plan

I will desiccate her high and Janet granuloma.

Will treat her losing rash with Burro solution soaks, followed by topical spheroids.

She was worried that she has precancerous cemented lesions, but I see no indication that she dies.

She will clean her hands less often, otherwise he will have Cirrhosis from Washington. She will moisturize with Aqua 4.

While outdoors, she will protect herself from the son.

For acne, recommended isotretinoin, enrolled patient in iPledge program. She cannot have a fasting blood test today, as she 8 this morning. He will obtain a pregnancy test, and I will confirm patient’s cuddling.

My staph will send a report of today’s visit to the patient’s Coronary Physician.

Dr. Rockoff practices dermatology in Brookline, Mass. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

At this ripe point in my career, many new patients come referred by Dr. Google. “I checked the Internet,” they say. “You have great reviews.”

I don’t read my reviews. The abusive ones make me ill. People must filter out the bile and focus on the positives.

Laymen have little sense of how good the professionals they consult really are. Unless I’m audited and lose, how would I know how skillful my accountant is? My urologist is a nice man. How good is he at prostate surgery? I hope not to find out. Nevertheless, reviews are here to stay, as are physician evaluations by insurers and professional agencies.

Some office days highlight the gap, really the chasm, between the truth of the professional matter and what makes patients decide to trust or mistrust us. Last Thursday was one of those days.

Marla brought in her daughter, aged 3 years. Zoe had a scaly rash and some red papules on her arms and legs.

“Did your pediatrician treat this?” I asked.

“No, I came right to you,” said Marla. “You diagnosed her with bedbugs when she was an infant. The pediatricians had no idea what was going on. I trust you.”

That is flattering, but if I were being fully honest, I would tell Marla:

•  Bedbug bites are tricky to diagnose. I’ve missed my share.

•  What helped me diagnose them in her daughter was that the pediatrician had already tried several remedies that hadn’t helped.

Even if I said these things, though – and why waste all that wonderful transference? – Marla would probably have said, “Maybe so, but you got it right, and I trust you.” Nothing succeeds like success.

The reverse, however, is also true: Nothing fails like failure.

Later the same day Brian brought in Luke, aged 6 years. Luke has severe atopic dermatitis. As usual, he was scratching up a storm. “I think it’s infected,” Brian said. “Shouldn’t he take antibiotics?”

I examined Luke and found subacute eczema. “I don’t think so,” I said. “This is what Luke’s eczema flares look like. Let’s treat him with a topical steroid cream and see how he does.”

“But he had staph last year,” said Brian.

“I recall,” I said, “but most of his outbreaks have not been infected, and it doesn’t look like staph now. Let’s treat it as we usually do and see what happens over the next week.”

Two weeks later Brian brought back Luke, still scratching. There were still no pustules or deeper inflammatory lesions. We started Luke on an antibiotic, and swabbed scratched areas. Two days later the culture grew staph. By the time I called Brian with the results, he had brought Luke to an emergency room. “He has abscesses,” he told me.

The next day the sensitivities were back, confirming staph. I called Brian, who had this to say: “He should have been on antibiotics 2 weeks ago. From now on, whenever he starts scratching, he should be started on them right away. I won’t be bringing him back to your practice. I don’t trust you. I trust the doctors in the ER more.”

Is it really a good idea to start every eczema patient on antibiotics? How about every eczema patient who once had staph? Based on my own clinical experience with both conditions, I would answer both questions in the negative. Others might disagree.

One thing is sure, though: Like most patients, Brian sees the situation not through the eyes of my experience but through his own case series, with an n of 1. But that 1 carries a lot of weight, because the 1 is Luke, his son. It is therefore clear – to him – that his son should be treated preemptively with antibiotics for every eczema flare.

At this point I might too, for Luke, but I will not get the chance. Once trust is gone, the clinical relationship is over. Sometimes it’s one strike and you’re out.

For her part, Marla sees things through her single case report as well, drawing the opposite conclusion: that my success earned me the trust her pediatrician lost.

The subtleties and nuances of such cases, which every clinician knows, are lost in the often black-and-white world of lay reviews and pay-for-performance algorithms. That’s clinical life.

Trust me.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

At this ripe point in my career, many new patients come referred by Dr. Google. “I checked the Internet,” they say. “You have great reviews.”

I don’t read my reviews. The abusive ones make me ill. People must filter out the bile and focus on the positives.

Laymen have little sense of how good the professionals they consult really are. Unless I’m audited and lose, how would I know how skillful my accountant is? My urologist is a nice man. How good is he at prostate surgery? I hope not to find out. Nevertheless, reviews are here to stay, as are physician evaluations by insurers and professional agencies.

Some office days highlight the gap, really the chasm, between the truth of the professional matter and what makes patients decide to trust or mistrust us. Last Thursday was one of those days.

Marla brought in her daughter, aged 3 years. Zoe had a scaly rash and some red papules on her arms and legs.

“Did your pediatrician treat this?” I asked.

“No, I came right to you,” said Marla. “You diagnosed her with bedbugs when she was an infant. The pediatricians had no idea what was going on. I trust you.”

That is flattering, but if I were being fully honest, I would tell Marla:

•  Bedbug bites are tricky to diagnose. I’ve missed my share.

•  What helped me diagnose them in her daughter was that the pediatrician had already tried several remedies that hadn’t helped.

Even if I said these things, though – and why waste all that wonderful transference? – Marla would probably have said, “Maybe so, but you got it right, and I trust you.” Nothing succeeds like success.

The reverse, however, is also true: Nothing fails like failure.

Later the same day Brian brought in Luke, aged 6 years. Luke has severe atopic dermatitis. As usual, he was scratching up a storm. “I think it’s infected,” Brian said. “Shouldn’t he take antibiotics?”

I examined Luke and found subacute eczema. “I don’t think so,” I said. “This is what Luke’s eczema flares look like. Let’s treat him with a topical steroid cream and see how he does.”

“But he had staph last year,” said Brian.

“I recall,” I said, “but most of his outbreaks have not been infected, and it doesn’t look like staph now. Let’s treat it as we usually do and see what happens over the next week.”

Two weeks later Brian brought back Luke, still scratching. There were still no pustules or deeper inflammatory lesions. We started Luke on an antibiotic, and swabbed scratched areas. Two days later the culture grew staph. By the time I called Brian with the results, he had brought Luke to an emergency room. “He has abscesses,” he told me.

The next day the sensitivities were back, confirming staph. I called Brian, who had this to say: “He should have been on antibiotics 2 weeks ago. From now on, whenever he starts scratching, he should be started on them right away. I won’t be bringing him back to your practice. I don’t trust you. I trust the doctors in the ER more.”

Is it really a good idea to start every eczema patient on antibiotics? How about every eczema patient who once had staph? Based on my own clinical experience with both conditions, I would answer both questions in the negative. Others might disagree.

One thing is sure, though: Like most patients, Brian sees the situation not through the eyes of my experience but through his own case series, with an n of 1. But that 1 carries a lot of weight, because the 1 is Luke, his son. It is therefore clear – to him – that his son should be treated preemptively with antibiotics for every eczema flare.

At this point I might too, for Luke, but I will not get the chance. Once trust is gone, the clinical relationship is over. Sometimes it’s one strike and you’re out.

For her part, Marla sees things through her single case report as well, drawing the opposite conclusion: that my success earned me the trust her pediatrician lost.

The subtleties and nuances of such cases, which every clinician knows, are lost in the often black-and-white world of lay reviews and pay-for-performance algorithms. That’s clinical life.

Trust me.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

At this ripe point in my career, many new patients come referred by Dr. Google. “I checked the Internet,” they say. “You have great reviews.”

I don’t read my reviews. The abusive ones make me ill. People must filter out the bile and focus on the positives.

Laymen have little sense of how good the professionals they consult really are. Unless I’m audited and lose, how would I know how skillful my accountant is? My urologist is a nice man. How good is he at prostate surgery? I hope not to find out. Nevertheless, reviews are here to stay, as are physician evaluations by insurers and professional agencies.

Some office days highlight the gap, really the chasm, between the truth of the professional matter and what makes patients decide to trust or mistrust us. Last Thursday was one of those days.

Marla brought in her daughter, aged 3 years. Zoe had a scaly rash and some red papules on her arms and legs.

“Did your pediatrician treat this?” I asked.

“No, I came right to you,” said Marla. “You diagnosed her with bedbugs when she was an infant. The pediatricians had no idea what was going on. I trust you.”

That is flattering, but if I were being fully honest, I would tell Marla:

•  Bedbug bites are tricky to diagnose. I’ve missed my share.

•  What helped me diagnose them in her daughter was that the pediatrician had already tried several remedies that hadn’t helped.

Even if I said these things, though – and why waste all that wonderful transference? – Marla would probably have said, “Maybe so, but you got it right, and I trust you.” Nothing succeeds like success.

The reverse, however, is also true: Nothing fails like failure.

Later the same day Brian brought in Luke, aged 6 years. Luke has severe atopic dermatitis. As usual, he was scratching up a storm. “I think it’s infected,” Brian said. “Shouldn’t he take antibiotics?”

I examined Luke and found subacute eczema. “I don’t think so,” I said. “This is what Luke’s eczema flares look like. Let’s treat him with a topical steroid cream and see how he does.”

“But he had staph last year,” said Brian.

“I recall,” I said, “but most of his outbreaks have not been infected, and it doesn’t look like staph now. Let’s treat it as we usually do and see what happens over the next week.”

Two weeks later Brian brought back Luke, still scratching. There were still no pustules or deeper inflammatory lesions. We started Luke on an antibiotic, and swabbed scratched areas. Two days later the culture grew staph. By the time I called Brian with the results, he had brought Luke to an emergency room. “He has abscesses,” he told me.

The next day the sensitivities were back, confirming staph. I called Brian, who had this to say: “He should have been on antibiotics 2 weeks ago. From now on, whenever he starts scratching, he should be started on them right away. I won’t be bringing him back to your practice. I don’t trust you. I trust the doctors in the ER more.”

Is it really a good idea to start every eczema patient on antibiotics? How about every eczema patient who once had staph? Based on my own clinical experience with both conditions, I would answer both questions in the negative. Others might disagree.

One thing is sure, though: Like most patients, Brian sees the situation not through the eyes of my experience but through his own case series, with an n of 1. But that 1 carries a lot of weight, because the 1 is Luke, his son. It is therefore clear – to him – that his son should be treated preemptively with antibiotics for every eczema flare.

At this point I might too, for Luke, but I will not get the chance. Once trust is gone, the clinical relationship is over. Sometimes it’s one strike and you’re out.

For her part, Marla sees things through her single case report as well, drawing the opposite conclusion: that my success earned me the trust her pediatrician lost.

The subtleties and nuances of such cases, which every clinician knows, are lost in the often black-and-white world of lay reviews and pay-for-performance algorithms. That’s clinical life.

Trust me.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

It seemed like a teachable moment. My student looked on as Laura took off her shoes and showed us livid, polycyclic plaques covering the dorsum of her left foot. The way her rash looked, bordering 10 obviously fungal toenails, left little doubt about the problem.

“I’m going to guess you’re using a steroid cream,” I said.

“Could I please tell you the whole story?” said Laura, with some impatience.

“Sure,” I said. I love whole stories.

So Laura told me hers, starting with her walk through the tall grass in the summer, followed by “poison ivy” that her primary care physician treated with “a cream.”

“Did the cream have hydrocortisone in it?”

“I think so,” she said. But that didn’t work, so her doctor prescribed another cream. That one seemed to help a bit, but then the rash got redder and itchier, so she got another cream. “I think it was called clobetasol,” Laura said.

“Several years ago,” Laura went on, “you said I had toenail fungus in my nails, but I didn’t want to take pills for it because it didn’t bother me enough.”

“Maybe now would be a good time,” I said.

After I had recommended oral and topical therapy (and stopped the clobetasol!), my student and I went into my office. Like most of my students, she is headed for a career in primary care, in her case, Family Medicine.

“What do you think?” I asked her. “How does this case reflect on the state of dermatology expertise in the primary care community?” We’ve been discussing this, because Laura’s was not the first such example, just the most egregious.

My student’s eyes widened. No need to belabor the point.

“The problem is not that Laura’s primary care physician made a mistake,” I said. “I make them too, like prescribing antifungal creams for eczema and steroid creams for fungi. The problem is not noticing that you’ve made the mistake – with the evidence literally staring you in the face – and then either fixing it, or else consulting someone else who can help you fix it.”

“I’m going to do a better job!” said my student, with feeling.

Perhaps she will. At least she will graduate medical school having learned that there is such a thing as nummular eczema and been told that not every round rash is a fungus. As with almost every 4th-year student who’s taken my elective for the last 35 years, she had little dermatology exposure until now beyond a couple of PowerPoint shows of exotic diseases. I had none either back in school, when dinosaurs roamed the earth.

After I graduated, my prestigious pediatric residency taught me a grand total of three dermatologic facts: 1. For tinea capitis, shine a Wood’s light on the scalp; 2. For pityriasis rosea, shine a Wood’s light on the body; and 3. If a groin wash involves the inguinal fold, it’s a yeast infection. I learned a lot, didn’t I?

Reflecting on Lesson #1, Trichophyton tonsurans, which doesn’t fluoresce, has predominated for half a century (and 90% of the time, the problem is seborrhea anyway). As for #2 and #3, never mind.

Decade after decade, the patients troop in: Eczemas treated as fungi, fungi treated with steroids, itchy rashes treated with permethrin, then treated again because the itch didn’t stop, because you can’t kill bugs that aren’t there.

Clinical dermatology is not rocket science. Eczema and fungus are so common that it is hardly possible not to encounter them in daily practice. Generations of providers come and go, yet the same clinical missteps persist.

Why are the common skin problems of ordinary patients not a priority in medical education? Why do so many practitioners keep doing the same things and not get better at doing them?

Perhaps such common problems just pass under the educational radar. Maybe these diseases aren’t sexy enough, their poor outcomes not consequential enough. Maybe the shoe just doesn’t pinch hard enough on these itchy, polycyclic plaques.

My students are very young and earnest. They mean to get out into the world and do a good job. Many challenges before them, which now include crushing, mind-numbing bureaucratic demands. Can we ask that, while they are busy clicking drop-down boxes on their EHR’s and mastering genomic medicine, they also treat eczema as eczema and fungus as fungus?

One hopes so.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

It seemed like a teachable moment. My student looked on as Laura took off her shoes and showed us livid, polycyclic plaques covering the dorsum of her left foot. The way her rash looked, bordering 10 obviously fungal toenails, left little doubt about the problem.

“I’m going to guess you’re using a steroid cream,” I said.

“Could I please tell you the whole story?” said Laura, with some impatience.

“Sure,” I said. I love whole stories.

So Laura told me hers, starting with her walk through the tall grass in the summer, followed by “poison ivy” that her primary care physician treated with “a cream.”

“Did the cream have hydrocortisone in it?”

“I think so,” she said. But that didn’t work, so her doctor prescribed another cream. That one seemed to help a bit, but then the rash got redder and itchier, so she got another cream. “I think it was called clobetasol,” Laura said.

“Several years ago,” Laura went on, “you said I had toenail fungus in my nails, but I didn’t want to take pills for it because it didn’t bother me enough.”

“Maybe now would be a good time,” I said.

After I had recommended oral and topical therapy (and stopped the clobetasol!), my student and I went into my office. Like most of my students, she is headed for a career in primary care, in her case, Family Medicine.

“What do you think?” I asked her. “How does this case reflect on the state of dermatology expertise in the primary care community?” We’ve been discussing this, because Laura’s was not the first such example, just the most egregious.

My student’s eyes widened. No need to belabor the point.

“The problem is not that Laura’s primary care physician made a mistake,” I said. “I make them too, like prescribing antifungal creams for eczema and steroid creams for fungi. The problem is not noticing that you’ve made the mistake – with the evidence literally staring you in the face – and then either fixing it, or else consulting someone else who can help you fix it.”

“I’m going to do a better job!” said my student, with feeling.

Perhaps she will. At least she will graduate medical school having learned that there is such a thing as nummular eczema and been told that not every round rash is a fungus. As with almost every 4th-year student who’s taken my elective for the last 35 years, she had little dermatology exposure until now beyond a couple of PowerPoint shows of exotic diseases. I had none either back in school, when dinosaurs roamed the earth.

After I graduated, my prestigious pediatric residency taught me a grand total of three dermatologic facts: 1. For tinea capitis, shine a Wood’s light on the scalp; 2. For pityriasis rosea, shine a Wood’s light on the body; and 3. If a groin wash involves the inguinal fold, it’s a yeast infection. I learned a lot, didn’t I?

Reflecting on Lesson #1, Trichophyton tonsurans, which doesn’t fluoresce, has predominated for half a century (and 90% of the time, the problem is seborrhea anyway). As for #2 and #3, never mind.

Decade after decade, the patients troop in: Eczemas treated as fungi, fungi treated with steroids, itchy rashes treated with permethrin, then treated again because the itch didn’t stop, because you can’t kill bugs that aren’t there.

Clinical dermatology is not rocket science. Eczema and fungus are so common that it is hardly possible not to encounter them in daily practice. Generations of providers come and go, yet the same clinical missteps persist.

Why are the common skin problems of ordinary patients not a priority in medical education? Why do so many practitioners keep doing the same things and not get better at doing them?

Perhaps such common problems just pass under the educational radar. Maybe these diseases aren’t sexy enough, their poor outcomes not consequential enough. Maybe the shoe just doesn’t pinch hard enough on these itchy, polycyclic plaques.

My students are very young and earnest. They mean to get out into the world and do a good job. Many challenges before them, which now include crushing, mind-numbing bureaucratic demands. Can we ask that, while they are busy clicking drop-down boxes on their EHR’s and mastering genomic medicine, they also treat eczema as eczema and fungus as fungus?

One hopes so.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

It seemed like a teachable moment. My student looked on as Laura took off her shoes and showed us livid, polycyclic plaques covering the dorsum of her left foot. The way her rash looked, bordering 10 obviously fungal toenails, left little doubt about the problem.

“I’m going to guess you’re using a steroid cream,” I said.

“Could I please tell you the whole story?” said Laura, with some impatience.

“Sure,” I said. I love whole stories.

So Laura told me hers, starting with her walk through the tall grass in the summer, followed by “poison ivy” that her primary care physician treated with “a cream.”

“Did the cream have hydrocortisone in it?”

“I think so,” she said. But that didn’t work, so her doctor prescribed another cream. That one seemed to help a bit, but then the rash got redder and itchier, so she got another cream. “I think it was called clobetasol,” Laura said.

“Several years ago,” Laura went on, “you said I had toenail fungus in my nails, but I didn’t want to take pills for it because it didn’t bother me enough.”

“Maybe now would be a good time,” I said.

After I had recommended oral and topical therapy (and stopped the clobetasol!), my student and I went into my office. Like most of my students, she is headed for a career in primary care, in her case, Family Medicine.

“What do you think?” I asked her. “How does this case reflect on the state of dermatology expertise in the primary care community?” We’ve been discussing this, because Laura’s was not the first such example, just the most egregious.

My student’s eyes widened. No need to belabor the point.

“The problem is not that Laura’s primary care physician made a mistake,” I said. “I make them too, like prescribing antifungal creams for eczema and steroid creams for fungi. The problem is not noticing that you’ve made the mistake – with the evidence literally staring you in the face – and then either fixing it, or else consulting someone else who can help you fix it.”

“I’m going to do a better job!” said my student, with feeling.

Perhaps she will. At least she will graduate medical school having learned that there is such a thing as nummular eczema and been told that not every round rash is a fungus. As with almost every 4th-year student who’s taken my elective for the last 35 years, she had little dermatology exposure until now beyond a couple of PowerPoint shows of exotic diseases. I had none either back in school, when dinosaurs roamed the earth.

After I graduated, my prestigious pediatric residency taught me a grand total of three dermatologic facts: 1. For tinea capitis, shine a Wood’s light on the scalp; 2. For pityriasis rosea, shine a Wood’s light on the body; and 3. If a groin wash involves the inguinal fold, it’s a yeast infection. I learned a lot, didn’t I?

Reflecting on Lesson #1, Trichophyton tonsurans, which doesn’t fluoresce, has predominated for half a century (and 90% of the time, the problem is seborrhea anyway). As for #2 and #3, never mind.

Decade after decade, the patients troop in: Eczemas treated as fungi, fungi treated with steroids, itchy rashes treated with permethrin, then treated again because the itch didn’t stop, because you can’t kill bugs that aren’t there.

Clinical dermatology is not rocket science. Eczema and fungus are so common that it is hardly possible not to encounter them in daily practice. Generations of providers come and go, yet the same clinical missteps persist.

Why are the common skin problems of ordinary patients not a priority in medical education? Why do so many practitioners keep doing the same things and not get better at doing them?

Perhaps such common problems just pass under the educational radar. Maybe these diseases aren’t sexy enough, their poor outcomes not consequential enough. Maybe the shoe just doesn’t pinch hard enough on these itchy, polycyclic plaques.

My students are very young and earnest. They mean to get out into the world and do a good job. Many challenges before them, which now include crushing, mind-numbing bureaucratic demands. Can we ask that, while they are busy clicking drop-down boxes on their EHR’s and mastering genomic medicine, they also treat eczema as eczema and fungus as fungus?

One hopes so.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

My plane doesn’t leave till 2:30. Glad I cut off seeing patients at 11, which should give me plenty of time. I’m getting smarter in my old age.

Smooth morning, paperwork pretty much done. Just one patient left. Look, a nice little old man. He has such a sweet smile.

“How can I help you, Mr. Goldfarb?”

“It’s complicated. This letter explains everything that’s happened the past 3 years,”

Oh-oh, that doesn’t sound good. “OK, let’s have a look.”

“My, you read fast, Doctor.”

When the first line says, ‘The lice all over my body don’t go away even after I apply bug shampoo every day,’ I’m pretty much done.

“Doctor, this bag has everything I’ve used: lice shampoo, insect spray, itch lotion. I forgot to bring in all the little bugs I collected from my combs and sheets.”

No! This can’t be happening! How do I negotiate with a delusion and still make my plane?

“Sometimes it feels like bugs are crawling on my skin.”

“Itching often feels that way ... ”

“I brought pictures. Want to see?”

No! Not an album! Snap after snap: scabs on the scalp, scaling at the corners of the mouth, linear scratches on the extremities.

“You know, Mr. Goldfarb – maybe firm confidence will let me regain control of this interview – what you’re describing does not sound like lice or bugs of any kind ... ”

“But Doctor, how do you explain this?” Another photo, this of a comb filled with brownish epidermal fragments. “I meant to bring some in, but I forgot.”

Enough. Time to look grim and speak briskly. “Mr. Goldfarb, this cannot be lice because ... ”

“I see them coming out of all my pores ... ”

“Mr. Goldfarb!” Now it’s my turn to interrupt. “I would appreciate it if you would let me finish my sentence.”

“Yes, Doctor. If it’s not lice, what do you think it is?”

Must think fast. “Sensitivity. Sensitive skin, especially if you’ve scratched it, can certainly feel as though there are things crawling on you. Patients often say that the skin feels this way. I will therefore treat this sensitivity with anti-inflammatory creams and lotion you will apply to the scalp, face, and the rest of your body respectively.”

Goldfarb is still listening. I’m almost there.

“I want you to use this medication for 2 weeks without stopping, and not use any more of the bug shampoos and creams because they can be irritating and increase itch and sensitivity. Please call me on my private extension at that point with your progress.” Easier to deny a delusion when not standing face to face.

“That’s good news, Doctor. I’ll pick up the medication and let you know.”

At most, he’ll stop scratching for a while. By the time he starts again, I’ll have made my plane and come back to the office. Meantime: Depart exam room briskly!

I can still make it if I leave right away. One last check of my office e-mail. There’s one from Zelda. She has a small scaly patch on one forearm. Claims it’s responded neither to topical antifungals nor steroids.

Here’s the text of her e-mail: “Doctor, I showed my rash to my neighbor Mary. She did some Internet research, and she’s convinced it’s chromoblastomycosis. I’m pretty sure she’s right. What do you think?”

I think I better leave right now.

My reply: “Dear Zelda, pretty unlikely. Try the new cream I’m going to prescribe for 2 weeks, and let me check on how you’re doing.”

How does evil dermatologic karma know that I’m trying to leave town? Parasitosis and chromoblastomycosis! Can this be a bad dream? If so, why don’t I wake up?

Mr. Goldfarb, still looking sweet and mild, sits in the waiting room, awaiting the elder shuttle to take him home.

Walk fast. Do not smile and meet his gaze. This is no time for politeness.

No, sir. I am outta here.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

My plane doesn’t leave till 2:30. Glad I cut off seeing patients at 11, which should give me plenty of time. I’m getting smarter in my old age.

Smooth morning, paperwork pretty much done. Just one patient left. Look, a nice little old man. He has such a sweet smile.

“How can I help you, Mr. Goldfarb?”

“It’s complicated. This letter explains everything that’s happened the past 3 years,”

Oh-oh, that doesn’t sound good. “OK, let’s have a look.”

“My, you read fast, Doctor.”

When the first line says, ‘The lice all over my body don’t go away even after I apply bug shampoo every day,’ I’m pretty much done.

“Doctor, this bag has everything I’ve used: lice shampoo, insect spray, itch lotion. I forgot to bring in all the little bugs I collected from my combs and sheets.”

No! This can’t be happening! How do I negotiate with a delusion and still make my plane?

“Sometimes it feels like bugs are crawling on my skin.”

“Itching often feels that way ... ”

“I brought pictures. Want to see?”

No! Not an album! Snap after snap: scabs on the scalp, scaling at the corners of the mouth, linear scratches on the extremities.

“You know, Mr. Goldfarb – maybe firm confidence will let me regain control of this interview – what you’re describing does not sound like lice or bugs of any kind ... ”

“But Doctor, how do you explain this?” Another photo, this of a comb filled with brownish epidermal fragments. “I meant to bring some in, but I forgot.”

Enough. Time to look grim and speak briskly. “Mr. Goldfarb, this cannot be lice because ... ”

“I see them coming out of all my pores ... ”

“Mr. Goldfarb!” Now it’s my turn to interrupt. “I would appreciate it if you would let me finish my sentence.”

“Yes, Doctor. If it’s not lice, what do you think it is?”

Must think fast. “Sensitivity. Sensitive skin, especially if you’ve scratched it, can certainly feel as though there are things crawling on you. Patients often say that the skin feels this way. I will therefore treat this sensitivity with anti-inflammatory creams and lotion you will apply to the scalp, face, and the rest of your body respectively.”

Goldfarb is still listening. I’m almost there.

“I want you to use this medication for 2 weeks without stopping, and not use any more of the bug shampoos and creams because they can be irritating and increase itch and sensitivity. Please call me on my private extension at that point with your progress.” Easier to deny a delusion when not standing face to face.

“That’s good news, Doctor. I’ll pick up the medication and let you know.”

At most, he’ll stop scratching for a while. By the time he starts again, I’ll have made my plane and come back to the office. Meantime: Depart exam room briskly!

I can still make it if I leave right away. One last check of my office e-mail. There’s one from Zelda. She has a small scaly patch on one forearm. Claims it’s responded neither to topical antifungals nor steroids.

Here’s the text of her e-mail: “Doctor, I showed my rash to my neighbor Mary. She did some Internet research, and she’s convinced it’s chromoblastomycosis. I’m pretty sure she’s right. What do you think?”

I think I better leave right now.

My reply: “Dear Zelda, pretty unlikely. Try the new cream I’m going to prescribe for 2 weeks, and let me check on how you’re doing.”

How does evil dermatologic karma know that I’m trying to leave town? Parasitosis and chromoblastomycosis! Can this be a bad dream? If so, why don’t I wake up?

Mr. Goldfarb, still looking sweet and mild, sits in the waiting room, awaiting the elder shuttle to take him home.

Walk fast. Do not smile and meet his gaze. This is no time for politeness.

No, sir. I am outta here.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

My plane doesn’t leave till 2:30. Glad I cut off seeing patients at 11, which should give me plenty of time. I’m getting smarter in my old age.

Smooth morning, paperwork pretty much done. Just one patient left. Look, a nice little old man. He has such a sweet smile.

“How can I help you, Mr. Goldfarb?”

“It’s complicated. This letter explains everything that’s happened the past 3 years,”

Oh-oh, that doesn’t sound good. “OK, let’s have a look.”

“My, you read fast, Doctor.”

When the first line says, ‘The lice all over my body don’t go away even after I apply bug shampoo every day,’ I’m pretty much done.

“Doctor, this bag has everything I’ve used: lice shampoo, insect spray, itch lotion. I forgot to bring in all the little bugs I collected from my combs and sheets.”

No! This can’t be happening! How do I negotiate with a delusion and still make my plane?

“Sometimes it feels like bugs are crawling on my skin.”

“Itching often feels that way ... ”

“I brought pictures. Want to see?”

No! Not an album! Snap after snap: scabs on the scalp, scaling at the corners of the mouth, linear scratches on the extremities.

“You know, Mr. Goldfarb – maybe firm confidence will let me regain control of this interview – what you’re describing does not sound like lice or bugs of any kind ... ”

“But Doctor, how do you explain this?” Another photo, this of a comb filled with brownish epidermal fragments. “I meant to bring some in, but I forgot.”

Enough. Time to look grim and speak briskly. “Mr. Goldfarb, this cannot be lice because ... ”

“I see them coming out of all my pores ... ”

“Mr. Goldfarb!” Now it’s my turn to interrupt. “I would appreciate it if you would let me finish my sentence.”

“Yes, Doctor. If it’s not lice, what do you think it is?”

Must think fast. “Sensitivity. Sensitive skin, especially if you’ve scratched it, can certainly feel as though there are things crawling on you. Patients often say that the skin feels this way. I will therefore treat this sensitivity with anti-inflammatory creams and lotion you will apply to the scalp, face, and the rest of your body respectively.”

Goldfarb is still listening. I’m almost there.

“I want you to use this medication for 2 weeks without stopping, and not use any more of the bug shampoos and creams because they can be irritating and increase itch and sensitivity. Please call me on my private extension at that point with your progress.” Easier to deny a delusion when not standing face to face.

“That’s good news, Doctor. I’ll pick up the medication and let you know.”

At most, he’ll stop scratching for a while. By the time he starts again, I’ll have made my plane and come back to the office. Meantime: Depart exam room briskly!

I can still make it if I leave right away. One last check of my office e-mail. There’s one from Zelda. She has a small scaly patch on one forearm. Claims it’s responded neither to topical antifungals nor steroids.

Here’s the text of her e-mail: “Doctor, I showed my rash to my neighbor Mary. She did some Internet research, and she’s convinced it’s chromoblastomycosis. I’m pretty sure she’s right. What do you think?”

I think I better leave right now.

My reply: “Dear Zelda, pretty unlikely. Try the new cream I’m going to prescribe for 2 weeks, and let me check on how you’re doing.”

How does evil dermatologic karma know that I’m trying to leave town? Parasitosis and chromoblastomycosis! Can this be a bad dream? If so, why don’t I wake up?

Mr. Goldfarb, still looking sweet and mild, sits in the waiting room, awaiting the elder shuttle to take him home.

Walk fast. Do not smile and meet his gaze. This is no time for politeness.

No, sir. I am outta here.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

Chutzpah is a Yiddish word that entered American English, joining bagel and nosh. The usual translations of chutzpah – “nerve” or “effrontery” – are correct enough, but leave out the zest implied by chutzpah’s classic case: a man who kills his parents and throws himself on the mercy of the court because he is an orphan.

We all meet patients with chutzpah, which can be amusing, impressive – even breathtaking.

Take for instance the woman who paged me one evening last month. “I visit your nurse for cosmetic stuff,” she said when I called her back. “Your prices for laser hair removal were high, though, so I went to a spa where I could use a Groupon.”

How nice, I thought.

“Anyhow,” she continued, “I went for a treatment at the spa today, and now I have little red bumps all over my thighs. I thought it might be a reaction, and since you are my dermatologist I called to ask what to do.”

Good to be needed.

Then the next week I got another call, this time from a man I hadn’t seen in a long time. “I really like you as a dermatologist,” he began.

“Thank you,” I murmured.

“I saw this spot on my leg that worried me,” he said. “I was going to show it to you, but your office is in an old building, and old buildings don’t agree with me.”

As I scratched my head, he went on. “So I went to another dermatologist who works in a newer building. He did a biopsy and told me I have skin cancer. He said I should have surgery to take it off. I consider you my dermatologist, though, so I called to ask whether you think surgery is a good idea.”

I said I thought it was. I did not add that he should look for an old surgeon in a new building.

These patients are fresh in my mind, but it doesn’t take much effort to come up with others.

“Mr. Skillman wants a refill on his steroid cream,” says my secretary.

“Sure,” I tell her. “E-scribe it over.”

“No,” she says. “He wants a hard copy mailed to him.”

“Does he have one of those mail order pharmacies that requires a written script?”

“No.”

“But it’s so much simpler to call it in or do it by computer. Why does he have to have a hard copy?”

“I don’t know. But he insists on having one.”

I could go on and on. So could you, I’m sure.

When confronted with chutzpah, you have two options: challenge the person showing it and refuse to go along with his demands, or just sigh, comply, and move on. In general, I go with option #2.

First of all, anyone pushy enough to act this way will not react well to being pushed back. (“What’s your problem? Are you too busy to write a prescription? Too stingy to mail it?”)

Second, and perhaps more to the point, many people who display chutzpah don’t know that’s what they are doing. The woman who went for laser at the Groupon spa really has no idea I’d think it odd for her to call me about a complication instead of the spa personnel who lasered her legs. On some level, she figures that they probably don’t know (look how cheap they are), and thinks I should be flattered to be asked. After all, I’m her dermatologist.

Some people with chutzpah are aggressive and difficult and don’t care if they’re being offensive. A lot more are just clueless. The fellow who bores the daylights out of everyone at dinner parties with long, pointless stories doesn’t know he’s being tedious. He just doesn’t pick up social cues.

Most patients, like most people, are polite and deferential. The rest, though, are more memorable.

My building is indeed old. One hundred years ago it was the swankiest apartment house around. Every flat had rooms for a butler, a maid, and a chauffeur for their Packard motorcar. Then the builder went belly-up during the Depression, and the new owner converted it to medical offices. Downward mobility works for me.

Faced with chutzpah, I shrug, smile, and get on with it. Enough people can still tolerate old buildings, and old dermatologists.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

Chutzpah is a Yiddish word that entered American English, joining bagel and nosh. The usual translations of chutzpah – “nerve” or “effrontery” – are correct enough, but leave out the zest implied by chutzpah’s classic case: a man who kills his parents and throws himself on the mercy of the court because he is an orphan.

We all meet patients with chutzpah, which can be amusing, impressive – even breathtaking.

Take for instance the woman who paged me one evening last month. “I visit your nurse for cosmetic stuff,” she said when I called her back. “Your prices for laser hair removal were high, though, so I went to a spa where I could use a Groupon.”

How nice, I thought.

“Anyhow,” she continued, “I went for a treatment at the spa today, and now I have little red bumps all over my thighs. I thought it might be a reaction, and since you are my dermatologist I called to ask what to do.”

Good to be needed.

Then the next week I got another call, this time from a man I hadn’t seen in a long time. “I really like you as a dermatologist,” he began.

“Thank you,” I murmured.

“I saw this spot on my leg that worried me,” he said. “I was going to show it to you, but your office is in an old building, and old buildings don’t agree with me.”

As I scratched my head, he went on. “So I went to another dermatologist who works in a newer building. He did a biopsy and told me I have skin cancer. He said I should have surgery to take it off. I consider you my dermatologist, though, so I called to ask whether you think surgery is a good idea.”

I said I thought it was. I did not add that he should look for an old surgeon in a new building.

These patients are fresh in my mind, but it doesn’t take much effort to come up with others.

“Mr. Skillman wants a refill on his steroid cream,” says my secretary.

“Sure,” I tell her. “E-scribe it over.”

“No,” she says. “He wants a hard copy mailed to him.”

“Does he have one of those mail order pharmacies that requires a written script?”

“No.”

“But it’s so much simpler to call it in or do it by computer. Why does he have to have a hard copy?”

“I don’t know. But he insists on having one.”

I could go on and on. So could you, I’m sure.

When confronted with chutzpah, you have two options: challenge the person showing it and refuse to go along with his demands, or just sigh, comply, and move on. In general, I go with option #2.

First of all, anyone pushy enough to act this way will not react well to being pushed back. (“What’s your problem? Are you too busy to write a prescription? Too stingy to mail it?”)

Second, and perhaps more to the point, many people who display chutzpah don’t know that’s what they are doing. The woman who went for laser at the Groupon spa really has no idea I’d think it odd for her to call me about a complication instead of the spa personnel who lasered her legs. On some level, she figures that they probably don’t know (look how cheap they are), and thinks I should be flattered to be asked. After all, I’m her dermatologist.

Some people with chutzpah are aggressive and difficult and don’t care if they’re being offensive. A lot more are just clueless. The fellow who bores the daylights out of everyone at dinner parties with long, pointless stories doesn’t know he’s being tedious. He just doesn’t pick up social cues.

Most patients, like most people, are polite and deferential. The rest, though, are more memorable.

My building is indeed old. One hundred years ago it was the swankiest apartment house around. Every flat had rooms for a butler, a maid, and a chauffeur for their Packard motorcar. Then the builder went belly-up during the Depression, and the new owner converted it to medical offices. Downward mobility works for me.

Faced with chutzpah, I shrug, smile, and get on with it. Enough people can still tolerate old buildings, and old dermatologists.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

Chutzpah is a Yiddish word that entered American English, joining bagel and nosh. The usual translations of chutzpah – “nerve” or “effrontery” – are correct enough, but leave out the zest implied by chutzpah’s classic case: a man who kills his parents and throws himself on the mercy of the court because he is an orphan.

We all meet patients with chutzpah, which can be amusing, impressive – even breathtaking.

Take for instance the woman who paged me one evening last month. “I visit your nurse for cosmetic stuff,” she said when I called her back. “Your prices for laser hair removal were high, though, so I went to a spa where I could use a Groupon.”

How nice, I thought.

“Anyhow,” she continued, “I went for a treatment at the spa today, and now I have little red bumps all over my thighs. I thought it might be a reaction, and since you are my dermatologist I called to ask what to do.”

Good to be needed.

Then the next week I got another call, this time from a man I hadn’t seen in a long time. “I really like you as a dermatologist,” he began.

“Thank you,” I murmured.

“I saw this spot on my leg that worried me,” he said. “I was going to show it to you, but your office is in an old building, and old buildings don’t agree with me.”

As I scratched my head, he went on. “So I went to another dermatologist who works in a newer building. He did a biopsy and told me I have skin cancer. He said I should have surgery to take it off. I consider you my dermatologist, though, so I called to ask whether you think surgery is a good idea.”

I said I thought it was. I did not add that he should look for an old surgeon in a new building.

These patients are fresh in my mind, but it doesn’t take much effort to come up with others.

“Mr. Skillman wants a refill on his steroid cream,” says my secretary.

“Sure,” I tell her. “E-scribe it over.”

“No,” she says. “He wants a hard copy mailed to him.”

“Does he have one of those mail order pharmacies that requires a written script?”

“No.”

“But it’s so much simpler to call it in or do it by computer. Why does he have to have a hard copy?”

“I don’t know. But he insists on having one.”

I could go on and on. So could you, I’m sure.

When confronted with chutzpah, you have two options: challenge the person showing it and refuse to go along with his demands, or just sigh, comply, and move on. In general, I go with option #2.

First of all, anyone pushy enough to act this way will not react well to being pushed back. (“What’s your problem? Are you too busy to write a prescription? Too stingy to mail it?”)

Second, and perhaps more to the point, many people who display chutzpah don’t know that’s what they are doing. The woman who went for laser at the Groupon spa really has no idea I’d think it odd for her to call me about a complication instead of the spa personnel who lasered her legs. On some level, she figures that they probably don’t know (look how cheap they are), and thinks I should be flattered to be asked. After all, I’m her dermatologist.

Some people with chutzpah are aggressive and difficult and don’t care if they’re being offensive. A lot more are just clueless. The fellow who bores the daylights out of everyone at dinner parties with long, pointless stories doesn’t know he’s being tedious. He just doesn’t pick up social cues.

Most patients, like most people, are polite and deferential. The rest, though, are more memorable.

My building is indeed old. One hundred years ago it was the swankiest apartment house around. Every flat had rooms for a butler, a maid, and a chauffeur for their Packard motorcar. Then the builder went belly-up during the Depression, and the new owner converted it to medical offices. Downward mobility works for me.

Faced with chutzpah, I shrug, smile, and get on with it. Enough people can still tolerate old buildings, and old dermatologists.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

Busy day at the office. Five different people asked when I plan to retire.

Dennis was first. I last saw him a year ago, as I’d been doing annually for 25 years. A few months later, he asked to have his records sent to his home. There was no obvious reason. Now he was back.

“I had an eventful year, medically,” he said. “You know, that biopsy you did on my nose was precancerous.”

I did know that. I had called him with the results. It was an actinic keratosis. I’d asked him to come back in a few months for me to recheck the area.

“I went to see another doctor,” he said. “He gave me a cream that made my skin turn red. I think it worked.”

It must have. After all, the keratosis had already been removed.

“But I didn’t like his office,” said Dennis, “so I decided to come back to you.”

Touching, I thought. “Nice to see you,” I said.

“I wanted a younger doctor,” said Dennis. “Someone who would be around for a while.”

“Well, I’m not planning to retire just yet.”

“Everyone retires eventually,” said Dennis.

“Yes,” I agreed. “I guess they do. See you next year.” Perhaps.

Well, that felt pretty good. Then I went in to see Phil.

“Good morning,” he said. “Are you thinking about retiring?”

“Not really,” I said.

“How old are you?” asked Phil.

“68,” I said.

Phil took a long look at me. “You look good,” he decided.

You don’t have to sound so surprised, I thought.

An hour later I saw Emma.

“I see you haven’t retired yet,” she said.

“No,” I replied. “It seems I haven’t. Would you like me to?”

“Oh, no!” said Emma. “I was just wondering. A lot of my doctors have been retiring.”

There it was. Fear of abandonment. Who will be there for me? I wanted to hold Emma’s hand and assure her that when the time came, someone would indeed be there for her when I wasn’t. But I didn’t. Like grown children, patients have to find out things like that for themselves.

A little later Mabel came by. Her rash was worrying her. “I saw a couple of doctors about it, but they didn’t seem to know what it was,” she said.

“It’s eczema,” I told her. “This is what I suggest you do.” I made some suggestions.

“I was here once before,” she said, “in the 80s. Then, when I couldn’t figure out what this rash I have was, I remembered your name. ‘No,’ I thought to myself. ‘He couldn’t possibly still be practicing.’ And then I found out that you were!”

Well, there you go.

This kind of thing can give you a complex. If so many people are surprised that you’re around, maybe you shouldn’t be. But the best was yet to come.

The last patient of the day was Jenna.

I introduced myself. “How did you get my name?” I asked. Nowadays, the most common answer I get goes something like, “I Googled you. I recognized your address and you got decent reviews.”

But Jenna answered, “My sister came here 10 years ago. She used to be a patient of Dr. Alvin Sherwin.”

“I took over Dr. Sherwin’s practice when he moved to Florida,” I told her. “That was in 1981, so it’s closer to 35 years ago, not 10.”

“My goodness,” she said. “That explains what my sister said.”

“What did your sister say?”

“Well, my mother found your name on a piece of paper. My mother likes to hold onto things.”

“I’ll say she does,” I said.

“My mother said, ‘Why don’t you call this guy Rockoff? He took care of your sister. He’s very good.’ So I looked you up and found your office.

“Anyway,” Jenna went on, “when I told my sister that I found you, she said, ‘Yes, I remember seeing him. You mean he’s still around? After all these years, I figured he was probably dead.’ ”

“Nope,” I said. “Not yet.”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Busy day at the office. Five different people asked when I plan to retire.

Dennis was first. I last saw him a year ago, as I’d been doing annually for 25 years. A few months later, he asked to have his records sent to his home. There was no obvious reason. Now he was back.

“I had an eventful year, medically,” he said. “You know, that biopsy you did on my nose was precancerous.”

I did know that. I had called him with the results. It was an actinic keratosis. I’d asked him to come back in a few months for me to recheck the area.

“I went to see another doctor,” he said. “He gave me a cream that made my skin turn red. I think it worked.”

It must have. After all, the keratosis had already been removed.

“But I didn’t like his office,” said Dennis, “so I decided to come back to you.”

Touching, I thought. “Nice to see you,” I said.

“I wanted a younger doctor,” said Dennis. “Someone who would be around for a while.”

“Well, I’m not planning to retire just yet.”

“Everyone retires eventually,” said Dennis.

“Yes,” I agreed. “I guess they do. See you next year.” Perhaps.

Well, that felt pretty good. Then I went in to see Phil.

“Good morning,” he said. “Are you thinking about retiring?”

“Not really,” I said.

“How old are you?” asked Phil.

“68,” I said.

Phil took a long look at me. “You look good,” he decided.

You don’t have to sound so surprised, I thought.

An hour later I saw Emma.

“I see you haven’t retired yet,” she said.

“No,” I replied. “It seems I haven’t. Would you like me to?”

“Oh, no!” said Emma. “I was just wondering. A lot of my doctors have been retiring.”

There it was. Fear of abandonment. Who will be there for me? I wanted to hold Emma’s hand and assure her that when the time came, someone would indeed be there for her when I wasn’t. But I didn’t. Like grown children, patients have to find out things like that for themselves.

A little later Mabel came by. Her rash was worrying her. “I saw a couple of doctors about it, but they didn’t seem to know what it was,” she said.

“It’s eczema,” I told her. “This is what I suggest you do.” I made some suggestions.

“I was here once before,” she said, “in the 80s. Then, when I couldn’t figure out what this rash I have was, I remembered your name. ‘No,’ I thought to myself. ‘He couldn’t possibly still be practicing.’ And then I found out that you were!”

Well, there you go.

This kind of thing can give you a complex. If so many people are surprised that you’re around, maybe you shouldn’t be. But the best was yet to come.

The last patient of the day was Jenna.

I introduced myself. “How did you get my name?” I asked. Nowadays, the most common answer I get goes something like, “I Googled you. I recognized your address and you got decent reviews.”

But Jenna answered, “My sister came here 10 years ago. She used to be a patient of Dr. Alvin Sherwin.”

“I took over Dr. Sherwin’s practice when he moved to Florida,” I told her. “That was in 1981, so it’s closer to 35 years ago, not 10.”

“My goodness,” she said. “That explains what my sister said.”

“What did your sister say?”

“Well, my mother found your name on a piece of paper. My mother likes to hold onto things.”

“I’ll say she does,” I said.

“My mother said, ‘Why don’t you call this guy Rockoff? He took care of your sister. He’s very good.’ So I looked you up and found your office.

“Anyway,” Jenna went on, “when I told my sister that I found you, she said, ‘Yes, I remember seeing him. You mean he’s still around? After all these years, I figured he was probably dead.’ ”

“Nope,” I said. “Not yet.”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Busy day at the office. Five different people asked when I plan to retire.

Dennis was first. I last saw him a year ago, as I’d been doing annually for 25 years. A few months later, he asked to have his records sent to his home. There was no obvious reason. Now he was back.

“I had an eventful year, medically,” he said. “You know, that biopsy you did on my nose was precancerous.”

I did know that. I had called him with the results. It was an actinic keratosis. I’d asked him to come back in a few months for me to recheck the area.

“I went to see another doctor,” he said. “He gave me a cream that made my skin turn red. I think it worked.”

It must have. After all, the keratosis had already been removed.

“But I didn’t like his office,” said Dennis, “so I decided to come back to you.”

Touching, I thought. “Nice to see you,” I said.

“I wanted a younger doctor,” said Dennis. “Someone who would be around for a while.”

“Well, I’m not planning to retire just yet.”

“Everyone retires eventually,” said Dennis.

“Yes,” I agreed. “I guess they do. See you next year.” Perhaps.

Well, that felt pretty good. Then I went in to see Phil.

“Good morning,” he said. “Are you thinking about retiring?”

“Not really,” I said.

“How old are you?” asked Phil.

“68,” I said.

Phil took a long look at me. “You look good,” he decided.

You don’t have to sound so surprised, I thought.

An hour later I saw Emma.

“I see you haven’t retired yet,” she said.

“No,” I replied. “It seems I haven’t. Would you like me to?”

“Oh, no!” said Emma. “I was just wondering. A lot of my doctors have been retiring.”

There it was. Fear of abandonment. Who will be there for me? I wanted to hold Emma’s hand and assure her that when the time came, someone would indeed be there for her when I wasn’t. But I didn’t. Like grown children, patients have to find out things like that for themselves.

A little later Mabel came by. Her rash was worrying her. “I saw a couple of doctors about it, but they didn’t seem to know what it was,” she said.

“It’s eczema,” I told her. “This is what I suggest you do.” I made some suggestions.

“I was here once before,” she said, “in the 80s. Then, when I couldn’t figure out what this rash I have was, I remembered your name. ‘No,’ I thought to myself. ‘He couldn’t possibly still be practicing.’ And then I found out that you were!”

Well, there you go.

This kind of thing can give you a complex. If so many people are surprised that you’re around, maybe you shouldn’t be. But the best was yet to come.

The last patient of the day was Jenna.

I introduced myself. “How did you get my name?” I asked. Nowadays, the most common answer I get goes something like, “I Googled you. I recognized your address and you got decent reviews.”

But Jenna answered, “My sister came here 10 years ago. She used to be a patient of Dr. Alvin Sherwin.”

“I took over Dr. Sherwin’s practice when he moved to Florida,” I told her. “That was in 1981, so it’s closer to 35 years ago, not 10.”

“My goodness,” she said. “That explains what my sister said.”

“What did your sister say?”

“Well, my mother found your name on a piece of paper. My mother likes to hold onto things.”

“I’ll say she does,” I said.

“My mother said, ‘Why don’t you call this guy Rockoff? He took care of your sister. He’s very good.’ So I looked you up and found your office.

“Anyway,” Jenna went on, “when I told my sister that I found you, she said, ‘Yes, I remember seeing him. You mean he’s still around? After all these years, I figured he was probably dead.’ ”

“Nope,” I said. “Not yet.”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].

An old joke about old jokes:

Three men have been friends for so long that to save time they tell jokes by number.

“38,” says one. Laughter.

“82,” says another. “That’s a good one!” say the others.

A puzzled onlooker decides to join in. “14!” he says. Stony silence. “What’s the matter?” he asks.

“You told it wrong,” they say.

Numbers are on my mind these days. ICD-10 is here. So many numbers. So little time.

As you recall, the ICD-10 rolled out on Oct. 1 after a year of postponement. Just before that date, a government spokesman sternly announced that doctors hoping for another reprieve were pipe-dreaming. “There will be no further delays,” he said. “Our ability to track Ebola and other epidemics depends on ICD-10.”

Ebola? Google helped me to understand. In the words of one health care consultant, ICD-9 has no specific code for Ebola, forcing doctors to use code 078.89: Other specified diseases due to viruses. This gave U.S. doctors no way to report and track Ebola. People were dying from inadequate classification.

I told this to a nonphysician friend, who asked, “Couldn’t they just make up a code for Ebola?” But that cannot be a good question, because no one of importance has asked it.

Now we have what we need: A98.4, Ebola virus disease, nestled between A98.1, Omsk hemorrhagic fever, and A98.8, Other specified viral hemorrhagic fevers. Note that these “Others” are specified. You must specify.

Now we can code for Ebola. And we have ICD-10, installed at a cost of untold billions of dollars spent by doctors, hospitals, billing services, and insurers. Armies of consultants stand ready to help all parties deal with the conversion. Things are bound to be better, though, for health care and for patients.

It is easy to make fun of ICD-10 by citing absurdities: V91.00XA, Burn due to merchant ship on fire, initial encounter. V97.33XD, Sucked into jet engine, subsequent encounter. (When will the silly fellow learn not to stand so close to jet engines?)

A truer flavor of dealing with the new classification system, however, comes from the degree of specificity – what the business-school types like to call granularity – that we now have to provide for the ordinary problems we clinicians encounter every day:

D23.10 Benign neoplasm, skin of eyelid.

D23.11 Other benign neoplasm of skin of right eyelid.

D23.12 Other benign neoplasm of skin of left eyelid.

Ditto for the ear, including external auditory canal, right or left (D23.21 and D23.22), unspecified parts of the face (D23.30), scalp and neck (D23.4), trunk (D23.5), right and left upper limb including shoulder, (D23.61 and D23.62), right and left lower limb, including hip (D23.71 and D23.72.) If you don’t know what side the lesion is on, you can use D23.70, Other benign neoplasm of skin of unspecified lower limb, including hip. But don’t use an unspecified code. We will be paid less if we don’t specify. Or so they say. Who knows, really? Even the payers don’t seem to know yet. We will find out.

I have a pain in an unspecified upper limb. I won’t say which. You will have to guess.

The same goes not just for skin cancers but for furuncles, lipomas, and so on. Furuncle of foot: L02.629. Furuncle of neck: L02.12. Furuncle of perineum: L02.225. There is also L02.229, furuncle of trunk, unspecified. Don’t go there. Specify. It is vital that we collect data on precisely which body parts furunculize.

In a current film, Matt Damon plays a man on Mars. Were he to return, he might look at all of this coding granularity and think the world has gone mad.

But that cannot be true, since no one of importance thinks so. And then of course there is Ebola.

Jokes by the numbers. Diseases by the numbers. Patients by the numbers. That’s why we became doctors, isn’t it? I don’t recall. It’s been a long time.

I end with a reverie:

The three men who tell jokes by numbers are sitting at tables. Each faces a rectangular card covered with white squares bordered in black. Red counters fill some of the squares.

The interloper who can’t tell a joke stands before them. “Toenail fungus,” he says.

One of the men leaps up.

“B35.1!” he cries.

“BINGO!”

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Write to him at [email protected].