Under My Skin

People hate bumps.

Bumps are ugly. Bumps are nasty. Bumps bother.

Seeing bumps makes people frown. Touching bumps makes them shudder.

Bumps on toads. Bumps on potatoes. Bumps on trees.

But especially bumps on skin – on faces, on lips, on tongues, on genitals. Bumps almost anywhere.

Bumps bother the people who have them. They especially agitate other people who have to look at them, so they point out the bumps and make it perfectly plain how bumps make them feel:

• "My wife says, ‘When are you going to get that disgusting red spot off your neck?’" (About a hemangioma.)

• "My kids say, ‘Dad, when are you getting that gross thing off your back?’" (About an epidermoid cyst.)

• "That black spot on your back – have you had that looked at?" (A doctor – not a dermatologist, of course – asks a patient about a dermal nevus you’ve been reassuring that patient about for years.)

"Just leave those skin tags on your neck alone," you say.

"But they’re nasty! Can’t you take them off?"

"I suggest you leave the cyst alone. Removing it would require surgery."

"But I hate it!"

Even nonverbal observers can call attention to bumps. More than one nursing mother has had me remove a mole from her breast, even though it’s been there without changing for a long time, because "the baby keeps grabbing at it."

But once the people who see bumps can talk, it’s open bump season. My wife had a blue nevus removed from her cheek many years ago. She recalls that she did it because our youngest son, about 8 years old at the time, kept pointing to her cheek and saying, "Blue nevus! Blue nevus!" (Yes, he could be irritating then, but no, he wasn’t diagnostically precocious – I’d told him what it was.)

That son now has three children of his own, so he can look to his own parenting challenges, not to mention his own blemishes.

The loaded words people apply to their bumps – ugly, disgusting, gross, nasty – are not the ones you’d expect, and they have nothing to do with histology or malignant potential. But if you listen for these words, you’ll hear them as often as I do.

Some of my bumpy conversations are droll in unexpected ways. Last week, for instance, Seth came in for his annual physical.

"I have these two things under my left arm," he said, pointing to a pair of skin tags.

"Do they bother you?" I asked.

"They bother my kids," he said. "Adam and Melissa keep pointing at them. They call them Fred."

"Fred? What do they call the other one?"

"Also Fred."

"Did you know," I asked him, "that all little thingies hanging off the body are male? People always say, ‘Can’t you get rid of those little guys?’ "

"I didn’t know that," said Seth.

"You see what you can learn at the dermatologist’s office?" I said. "If you want, I can make your kids happy and get rid of Fred. Both of him."

"Sure," said Seth. I loaded up my electric needle. I don’t play video games. Who needs when you have a Hyfrecator? Soon Fred was vaporized. BLAMMM! So was Fred. KAPOWW!

"Seth," I said, "if Dr. Seuss had written a book about dermatology, he might have called it ‘Bye, Bye, Fred’ and it may have gone like this":

See Fred.

Fred bled.

Fred bled red.

Fred bled red in bed.

Zap, Fred! Pow, Fred!

Now Fred is dead.

Sayonara, Fred.

Go ahead, moles, warts, skin tags, bumps of all kinds. Make my day.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

People hate bumps.

Bumps are ugly. Bumps are nasty. Bumps bother.

Seeing bumps makes people frown. Touching bumps makes them shudder.

Bumps on toads. Bumps on potatoes. Bumps on trees.

But especially bumps on skin – on faces, on lips, on tongues, on genitals. Bumps almost anywhere.

Bumps bother the people who have them. They especially agitate other people who have to look at them, so they point out the bumps and make it perfectly plain how bumps make them feel:

• "My wife says, ‘When are you going to get that disgusting red spot off your neck?’" (About a hemangioma.)

• "My kids say, ‘Dad, when are you getting that gross thing off your back?’" (About an epidermoid cyst.)

• "That black spot on your back – have you had that looked at?" (A doctor – not a dermatologist, of course – asks a patient about a dermal nevus you’ve been reassuring that patient about for years.)

"Just leave those skin tags on your neck alone," you say.

"But they’re nasty! Can’t you take them off?"

"I suggest you leave the cyst alone. Removing it would require surgery."

"But I hate it!"

Even nonverbal observers can call attention to bumps. More than one nursing mother has had me remove a mole from her breast, even though it’s been there without changing for a long time, because "the baby keeps grabbing at it."

But once the people who see bumps can talk, it’s open bump season. My wife had a blue nevus removed from her cheek many years ago. She recalls that she did it because our youngest son, about 8 years old at the time, kept pointing to her cheek and saying, "Blue nevus! Blue nevus!" (Yes, he could be irritating then, but no, he wasn’t diagnostically precocious – I’d told him what it was.)

That son now has three children of his own, so he can look to his own parenting challenges, not to mention his own blemishes.

The loaded words people apply to their bumps – ugly, disgusting, gross, nasty – are not the ones you’d expect, and they have nothing to do with histology or malignant potential. But if you listen for these words, you’ll hear them as often as I do.

Some of my bumpy conversations are droll in unexpected ways. Last week, for instance, Seth came in for his annual physical.

"I have these two things under my left arm," he said, pointing to a pair of skin tags.

"Do they bother you?" I asked.

"They bother my kids," he said. "Adam and Melissa keep pointing at them. They call them Fred."

"Fred? What do they call the other one?"

"Also Fred."

"Did you know," I asked him, "that all little thingies hanging off the body are male? People always say, ‘Can’t you get rid of those little guys?’ "

"I didn’t know that," said Seth.

"You see what you can learn at the dermatologist’s office?" I said. "If you want, I can make your kids happy and get rid of Fred. Both of him."

"Sure," said Seth. I loaded up my electric needle. I don’t play video games. Who needs when you have a Hyfrecator? Soon Fred was vaporized. BLAMMM! So was Fred. KAPOWW!

"Seth," I said, "if Dr. Seuss had written a book about dermatology, he might have called it ‘Bye, Bye, Fred’ and it may have gone like this":

See Fred.

Fred bled.

Fred bled red.

Fred bled red in bed.

Zap, Fred! Pow, Fred!

Now Fred is dead.

Sayonara, Fred.

Go ahead, moles, warts, skin tags, bumps of all kinds. Make my day.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

People hate bumps.

Bumps are ugly. Bumps are nasty. Bumps bother.

Seeing bumps makes people frown. Touching bumps makes them shudder.

Bumps on toads. Bumps on potatoes. Bumps on trees.

But especially bumps on skin – on faces, on lips, on tongues, on genitals. Bumps almost anywhere.

Bumps bother the people who have them. They especially agitate other people who have to look at them, so they point out the bumps and make it perfectly plain how bumps make them feel:

• "My wife says, ‘When are you going to get that disgusting red spot off your neck?’" (About a hemangioma.)

• "My kids say, ‘Dad, when are you getting that gross thing off your back?’" (About an epidermoid cyst.)

• "That black spot on your back – have you had that looked at?" (A doctor – not a dermatologist, of course – asks a patient about a dermal nevus you’ve been reassuring that patient about for years.)

"Just leave those skin tags on your neck alone," you say.

"But they’re nasty! Can’t you take them off?"

"I suggest you leave the cyst alone. Removing it would require surgery."

"But I hate it!"

Even nonverbal observers can call attention to bumps. More than one nursing mother has had me remove a mole from her breast, even though it’s been there without changing for a long time, because "the baby keeps grabbing at it."

But once the people who see bumps can talk, it’s open bump season. My wife had a blue nevus removed from her cheek many years ago. She recalls that she did it because our youngest son, about 8 years old at the time, kept pointing to her cheek and saying, "Blue nevus! Blue nevus!" (Yes, he could be irritating then, but no, he wasn’t diagnostically precocious – I’d told him what it was.)

That son now has three children of his own, so he can look to his own parenting challenges, not to mention his own blemishes.

The loaded words people apply to their bumps – ugly, disgusting, gross, nasty – are not the ones you’d expect, and they have nothing to do with histology or malignant potential. But if you listen for these words, you’ll hear them as often as I do.

Some of my bumpy conversations are droll in unexpected ways. Last week, for instance, Seth came in for his annual physical.

"I have these two things under my left arm," he said, pointing to a pair of skin tags.

"Do they bother you?" I asked.

"They bother my kids," he said. "Adam and Melissa keep pointing at them. They call them Fred."

"Fred? What do they call the other one?"

"Also Fred."

"Did you know," I asked him, "that all little thingies hanging off the body are male? People always say, ‘Can’t you get rid of those little guys?’ "

"I didn’t know that," said Seth.

"You see what you can learn at the dermatologist’s office?" I said. "If you want, I can make your kids happy and get rid of Fred. Both of him."

"Sure," said Seth. I loaded up my electric needle. I don’t play video games. Who needs when you have a Hyfrecator? Soon Fred was vaporized. BLAMMM! So was Fred. KAPOWW!

"Seth," I said, "if Dr. Seuss had written a book about dermatology, he might have called it ‘Bye, Bye, Fred’ and it may have gone like this":

See Fred.

Fred bled.

Fred bled red.

Fred bled red in bed.

Zap, Fred! Pow, Fred!

Now Fred is dead.

Sayonara, Fred.

Go ahead, moles, warts, skin tags, bumps of all kinds. Make my day.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My patients itch. Do yours?

This time of year, many of them say their backs itch, but the itch is not really their main concern. What worries them more is what the itch means. They know there are spots back there. They can feel them even if they can’t see them very well. Does the itch mean those spots are turning into something?

Sometimes those spots on their backs are moles. Sometimes they are seborrheic keratoses. But basically they’re all just innocent bystanders. Even if there does happen to be a superficial basal cell back there, any itch in the vicinity has nothing to do with any of the spots.

"Itching," I tell my patients, "is a sign that you are alive." After a short pause for mental processing, most of them smile. Being alive is good. Itch is your friend.

If they don’t smile and instead continue to look anguished, I sometimes freeze off some of their keratoses, just so they can feel reassured. You never know about those pesky growths. They’re benign today, but who knows about tomorrow? And they’re itchy, aren’t they? Doesn’t an itch mean something?

As far as I’m concerned, it doesn’t mean much, or at least not much about malignant transformation. Sometimes a cigar is just a cigar, and mostly an itch is just an itch. But to many of my patients, an itch is much more: Itch is change, itch is instability. Something is happening, something is changing, something is going on. Maybe one thing is turning into something else. Maybe it will.

Last week, I saw a thirtyish woman who wanted a skin check. One of her concerns was an itchy spot on her left shoulder. Lately, it had started to "move down" to her upper arm. As she admitted herself, there was absolutely nothing to be seen on the skin. She couldn’t possibly be worried about ...

Yes, she could. "This isn’t skin cancer, is it?" she asked. I assured her it was not. She seemed to believe me. I couldn’t remove anything anyway, because there was nothing to remove.

I don’t know where people get the idea that itch, especially when it applies to a mole or growth, means possible cancer. But wherever they get the idea, many of them certainly have it. They ask about it all the time. "I’m worried about that mole," they say.

"Do you think it’s changed, gotten larger or darker?"

"No, it looks the same. But now it itches."

People worry, not just about the itch, but about what happens when they scratch it. They’ve been warned since childhood not to scratch. Scratching can cause damage or infection. If what they’re scratching is a spot, then scratching can possibly turn the spot into ... don’t say it!

Of course, people complain about itching for a lot of reasons: They have eczema, or dry skin, or winter itch. Older folks have trouble sleeping because of itch. Office workers are embarrassed by itch – they have to leave meetings to keep their colleagues from twitching uncomfortably when they see them scratch. ("Like a monkey," is usually how they put it.) People who work in nursing homes or homeless shelters worry that they picked up a creepy-crawly from one of their clients. I once read that a king of England forbade commoners from scratching their itches, because scratching was so much fun that he wanted to reserve it for royalty. Couples married 7 years may get the itch. Treatises have been written about itching and scratching. I have not read them. Some things are better enjoyed than read about.

When the itch is accompanied by a visible rash – atopic eczema is the parade example – you treat the itch by treating the rash. When the patient has an itch but no rash other than scratch marks, it’s often best not just to treat the symptom, but to eliminate the worry that accompanies and exaggerates the symptom. No, the itch is not bugs. No, the itch is not liver disease. No, scratching will not cause damage, or you-know-what.

No, the itch is not cancer. There, I said it.

You itch. Itch is life. Celebrate!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My patients itch. Do yours?

This time of year, many of them say their backs itch, but the itch is not really their main concern. What worries them more is what the itch means. They know there are spots back there. They can feel them even if they can’t see them very well. Does the itch mean those spots are turning into something?

Sometimes those spots on their backs are moles. Sometimes they are seborrheic keratoses. But basically they’re all just innocent bystanders. Even if there does happen to be a superficial basal cell back there, any itch in the vicinity has nothing to do with any of the spots.

"Itching," I tell my patients, "is a sign that you are alive." After a short pause for mental processing, most of them smile. Being alive is good. Itch is your friend.

If they don’t smile and instead continue to look anguished, I sometimes freeze off some of their keratoses, just so they can feel reassured. You never know about those pesky growths. They’re benign today, but who knows about tomorrow? And they’re itchy, aren’t they? Doesn’t an itch mean something?

As far as I’m concerned, it doesn’t mean much, or at least not much about malignant transformation. Sometimes a cigar is just a cigar, and mostly an itch is just an itch. But to many of my patients, an itch is much more: Itch is change, itch is instability. Something is happening, something is changing, something is going on. Maybe one thing is turning into something else. Maybe it will.

Last week, I saw a thirtyish woman who wanted a skin check. One of her concerns was an itchy spot on her left shoulder. Lately, it had started to "move down" to her upper arm. As she admitted herself, there was absolutely nothing to be seen on the skin. She couldn’t possibly be worried about ...

Yes, she could. "This isn’t skin cancer, is it?" she asked. I assured her it was not. She seemed to believe me. I couldn’t remove anything anyway, because there was nothing to remove.

I don’t know where people get the idea that itch, especially when it applies to a mole or growth, means possible cancer. But wherever they get the idea, many of them certainly have it. They ask about it all the time. "I’m worried about that mole," they say.

"Do you think it’s changed, gotten larger or darker?"

"No, it looks the same. But now it itches."

People worry, not just about the itch, but about what happens when they scratch it. They’ve been warned since childhood not to scratch. Scratching can cause damage or infection. If what they’re scratching is a spot, then scratching can possibly turn the spot into ... don’t say it!

Of course, people complain about itching for a lot of reasons: They have eczema, or dry skin, or winter itch. Older folks have trouble sleeping because of itch. Office workers are embarrassed by itch – they have to leave meetings to keep their colleagues from twitching uncomfortably when they see them scratch. ("Like a monkey," is usually how they put it.) People who work in nursing homes or homeless shelters worry that they picked up a creepy-crawly from one of their clients. I once read that a king of England forbade commoners from scratching their itches, because scratching was so much fun that he wanted to reserve it for royalty. Couples married 7 years may get the itch. Treatises have been written about itching and scratching. I have not read them. Some things are better enjoyed than read about.

When the itch is accompanied by a visible rash – atopic eczema is the parade example – you treat the itch by treating the rash. When the patient has an itch but no rash other than scratch marks, it’s often best not just to treat the symptom, but to eliminate the worry that accompanies and exaggerates the symptom. No, the itch is not bugs. No, the itch is not liver disease. No, scratching will not cause damage, or you-know-what.

No, the itch is not cancer. There, I said it.

You itch. Itch is life. Celebrate!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My patients itch. Do yours?

This time of year, many of them say their backs itch, but the itch is not really their main concern. What worries them more is what the itch means. They know there are spots back there. They can feel them even if they can’t see them very well. Does the itch mean those spots are turning into something?

Sometimes those spots on their backs are moles. Sometimes they are seborrheic keratoses. But basically they’re all just innocent bystanders. Even if there does happen to be a superficial basal cell back there, any itch in the vicinity has nothing to do with any of the spots.

"Itching," I tell my patients, "is a sign that you are alive." After a short pause for mental processing, most of them smile. Being alive is good. Itch is your friend.

If they don’t smile and instead continue to look anguished, I sometimes freeze off some of their keratoses, just so they can feel reassured. You never know about those pesky growths. They’re benign today, but who knows about tomorrow? And they’re itchy, aren’t they? Doesn’t an itch mean something?

As far as I’m concerned, it doesn’t mean much, or at least not much about malignant transformation. Sometimes a cigar is just a cigar, and mostly an itch is just an itch. But to many of my patients, an itch is much more: Itch is change, itch is instability. Something is happening, something is changing, something is going on. Maybe one thing is turning into something else. Maybe it will.

Last week, I saw a thirtyish woman who wanted a skin check. One of her concerns was an itchy spot on her left shoulder. Lately, it had started to "move down" to her upper arm. As she admitted herself, there was absolutely nothing to be seen on the skin. She couldn’t possibly be worried about ...

Yes, she could. "This isn’t skin cancer, is it?" she asked. I assured her it was not. She seemed to believe me. I couldn’t remove anything anyway, because there was nothing to remove.

I don’t know where people get the idea that itch, especially when it applies to a mole or growth, means possible cancer. But wherever they get the idea, many of them certainly have it. They ask about it all the time. "I’m worried about that mole," they say.

"Do you think it’s changed, gotten larger or darker?"

"No, it looks the same. But now it itches."

People worry, not just about the itch, but about what happens when they scratch it. They’ve been warned since childhood not to scratch. Scratching can cause damage or infection. If what they’re scratching is a spot, then scratching can possibly turn the spot into ... don’t say it!

Of course, people complain about itching for a lot of reasons: They have eczema, or dry skin, or winter itch. Older folks have trouble sleeping because of itch. Office workers are embarrassed by itch – they have to leave meetings to keep their colleagues from twitching uncomfortably when they see them scratch. ("Like a monkey," is usually how they put it.) People who work in nursing homes or homeless shelters worry that they picked up a creepy-crawly from one of their clients. I once read that a king of England forbade commoners from scratching their itches, because scratching was so much fun that he wanted to reserve it for royalty. Couples married 7 years may get the itch. Treatises have been written about itching and scratching. I have not read them. Some things are better enjoyed than read about.

When the itch is accompanied by a visible rash – atopic eczema is the parade example – you treat the itch by treating the rash. When the patient has an itch but no rash other than scratch marks, it’s often best not just to treat the symptom, but to eliminate the worry that accompanies and exaggerates the symptom. No, the itch is not bugs. No, the itch is not liver disease. No, scratching will not cause damage, or you-know-what.

No, the itch is not cancer. There, I said it.

You itch. Itch is life. Celebrate!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

Our local Board of Registration in Medicine has a new requirement. To update a medical license, you have to take 3 hours of CME credit in opioid pain management, and another 2 hours in end-of-life issues. Fair enough. I prescribe OxyContin for my acne patients as often as the next dermatologist. As for end-of-life matters, a friend I told about the new regulation asked if I had many patients who wanted to end their lives. I said no, but I could think of a few patients who make me think about ending mine.

Anyhow, I took the courses as online webinars, featuring lecturers by academics from local medical institutions. Some of the information was likely to be helpful, at least for physicians in a position to use it often enough to remember it. Some was boilerplate, delivered in a monotone:

"As Sarkissian et al. found in a 2006 article published in the Journal of Annoying Interactions, 63% of patients seeking drugs may exhibit manipulative behavior." OK, thanks.

So you finish the webinar and take the post-module test. There are six questions, and you need to get four right. You pass. (Hooray!) Now you want to print out the CME certificate. But wait – first you have to take the Post Test Evaluation. So you click on the hyperlink, and there it is. The questions are in red, followed by open red circles. The first question is: How would you rate this presentation? 5 is Excellent, followed by Good, Fair, Poor, No Opinion, Not Applicable, and Nolo Contendere.

But here is the amazing part: 5 is already filled in! There’s a bright red circle staring you in the face. If you want to rate the presentation any way but Excellent, you have to change it by unclicking 5 and clicking a different circle.

In other words, they are not asking you to rate them Excellent. They are not telling you to rate them Excellent. They are doing it for you!

Surely, they must be kidding.

But they are not.

The other Evaluation questions range from irritating to inane:

• Did you find the presentation professional? (If you mark "No," you have to explain why. "I dunno, the shrink’s sport coat was kinda wrinkled.")

• Will it change your practice? (If you mark "Yes," you have to explain how. "I will not let patients manipulate me any more. Instead, I will hold my breath.")

• Did you find the presentation influenced by commercial considerations? ("Not really, except for the pop-up ads for methadone clinics.")

• Do you have any suggestions to improve future webinars? ("Maybe free opioid samples, so we can test out their half-lives for ourselves?")

So my by-default 5-ratings will be duly tabulated by little cyber-elves who live in statistical cyber-caverns, where they compile the data showing that the Massachusetts CME Consortium is indeed doing the Excellent Job that will entitle it to continue providing Continuing Education Courses of Excellence.

I don’t know how much any of this matters. Am I any smarter than I was before? Well, maybe in one way. Now I know what to do for myself:

Since you are reading this column, you have to rate it. The scale is from 1 to 5, with 5 being "Transcendent."

Please e-mail the editor of Skin & Allergy News. Tell her you want to give me a 6. Insist that she open a new category, so you can do it.

Never mind, I already told her, so we’re good.

You’re welcome, don’t mention it.

 Dr. Rockoff practices dermatology in Brookline, Mass.

Our local Board of Registration in Medicine has a new requirement. To update a medical license, you have to take 3 hours of CME credit in opioid pain management, and another 2 hours in end-of-life issues. Fair enough. I prescribe OxyContin for my acne patients as often as the next dermatologist. As for end-of-life matters, a friend I told about the new regulation asked if I had many patients who wanted to end their lives. I said no, but I could think of a few patients who make me think about ending mine.

Anyhow, I took the courses as online webinars, featuring lecturers by academics from local medical institutions. Some of the information was likely to be helpful, at least for physicians in a position to use it often enough to remember it. Some was boilerplate, delivered in a monotone:

"As Sarkissian et al. found in a 2006 article published in the Journal of Annoying Interactions, 63% of patients seeking drugs may exhibit manipulative behavior." OK, thanks.

So you finish the webinar and take the post-module test. There are six questions, and you need to get four right. You pass. (Hooray!) Now you want to print out the CME certificate. But wait – first you have to take the Post Test Evaluation. So you click on the hyperlink, and there it is. The questions are in red, followed by open red circles. The first question is: How would you rate this presentation? 5 is Excellent, followed by Good, Fair, Poor, No Opinion, Not Applicable, and Nolo Contendere.

But here is the amazing part: 5 is already filled in! There’s a bright red circle staring you in the face. If you want to rate the presentation any way but Excellent, you have to change it by unclicking 5 and clicking a different circle.

In other words, they are not asking you to rate them Excellent. They are not telling you to rate them Excellent. They are doing it for you!

Surely, they must be kidding.

But they are not.

The other Evaluation questions range from irritating to inane:

• Did you find the presentation professional? (If you mark "No," you have to explain why. "I dunno, the shrink’s sport coat was kinda wrinkled.")

• Will it change your practice? (If you mark "Yes," you have to explain how. "I will not let patients manipulate me any more. Instead, I will hold my breath.")

• Did you find the presentation influenced by commercial considerations? ("Not really, except for the pop-up ads for methadone clinics.")

• Do you have any suggestions to improve future webinars? ("Maybe free opioid samples, so we can test out their half-lives for ourselves?")

So my by-default 5-ratings will be duly tabulated by little cyber-elves who live in statistical cyber-caverns, where they compile the data showing that the Massachusetts CME Consortium is indeed doing the Excellent Job that will entitle it to continue providing Continuing Education Courses of Excellence.

I don’t know how much any of this matters. Am I any smarter than I was before? Well, maybe in one way. Now I know what to do for myself:

Since you are reading this column, you have to rate it. The scale is from 1 to 5, with 5 being "Transcendent."

Please e-mail the editor of Skin & Allergy News. Tell her you want to give me a 6. Insist that she open a new category, so you can do it.

Never mind, I already told her, so we’re good.

You’re welcome, don’t mention it.

 Dr. Rockoff practices dermatology in Brookline, Mass.

Our local Board of Registration in Medicine has a new requirement. To update a medical license, you have to take 3 hours of CME credit in opioid pain management, and another 2 hours in end-of-life issues. Fair enough. I prescribe OxyContin for my acne patients as often as the next dermatologist. As for end-of-life matters, a friend I told about the new regulation asked if I had many patients who wanted to end their lives. I said no, but I could think of a few patients who make me think about ending mine.

Anyhow, I took the courses as online webinars, featuring lecturers by academics from local medical institutions. Some of the information was likely to be helpful, at least for physicians in a position to use it often enough to remember it. Some was boilerplate, delivered in a monotone:

"As Sarkissian et al. found in a 2006 article published in the Journal of Annoying Interactions, 63% of patients seeking drugs may exhibit manipulative behavior." OK, thanks.

So you finish the webinar and take the post-module test. There are six questions, and you need to get four right. You pass. (Hooray!) Now you want to print out the CME certificate. But wait – first you have to take the Post Test Evaluation. So you click on the hyperlink, and there it is. The questions are in red, followed by open red circles. The first question is: How would you rate this presentation? 5 is Excellent, followed by Good, Fair, Poor, No Opinion, Not Applicable, and Nolo Contendere.

But here is the amazing part: 5 is already filled in! There’s a bright red circle staring you in the face. If you want to rate the presentation any way but Excellent, you have to change it by unclicking 5 and clicking a different circle.

In other words, they are not asking you to rate them Excellent. They are not telling you to rate them Excellent. They are doing it for you!

Surely, they must be kidding.

But they are not.

The other Evaluation questions range from irritating to inane:

• Did you find the presentation professional? (If you mark "No," you have to explain why. "I dunno, the shrink’s sport coat was kinda wrinkled.")

• Will it change your practice? (If you mark "Yes," you have to explain how. "I will not let patients manipulate me any more. Instead, I will hold my breath.")

• Did you find the presentation influenced by commercial considerations? ("Not really, except for the pop-up ads for methadone clinics.")

• Do you have any suggestions to improve future webinars? ("Maybe free opioid samples, so we can test out their half-lives for ourselves?")

So my by-default 5-ratings will be duly tabulated by little cyber-elves who live in statistical cyber-caverns, where they compile the data showing that the Massachusetts CME Consortium is indeed doing the Excellent Job that will entitle it to continue providing Continuing Education Courses of Excellence.

I don’t know how much any of this matters. Am I any smarter than I was before? Well, maybe in one way. Now I know what to do for myself:

Since you are reading this column, you have to rate it. The scale is from 1 to 5, with 5 being "Transcendent."

Please e-mail the editor of Skin & Allergy News. Tell her you want to give me a 6. Insist that she open a new category, so you can do it.

Never mind, I already told her, so we’re good.

You’re welcome, don’t mention it.

 Dr. Rockoff practices dermatology in Brookline, Mass.

My friend had a cyst removed from the end of her right fourth finger. She told me that it’s healing well and she’s happy with the doctor’s work.

"Who removed it?" I asked her.

She gave me the name of a hand surgeon at a local teaching hospital.

"Did you compare alternatives for cost?" I asked her.

She had gotten another surgical opinion, but didn’t really understand my question about cost comparison. My friend is a retired attorney who knows me well enough to realize I’m not always totally serious.

I told her about the current thrust to make consumers (i.e., patients) more cost conscious by giving them "more skin in the game" (making it worth their while to get the best deal they can, as they would when, say, buying a flat-screen TV).

When I explained to my friend what I meant, she told me she wasn’t sure how well that would work. I told her that although I have skin in the skin game, I’m not so sure either.

Changes are in the wind. I got an e-mail the other day from a patient whose leg I had recently biopsied. I had told him that the result showed a fairly large basal cell and recommended excision, suggesting either of two surgeons.

His answer was: "Thanks. I will compare their costs and let you know which one I pick."

I responded that doing that would be fine, but might be complicated by the fact that one of the surgeons does Mohs, so to compare prices he would need to consult that doctor first and find out which technique he would use.

Perhaps I shouldn’t have been put off by his e-mail, but I was. It seemed to imply that a professional recommendation is on the same plane as advice about picking a lawn mower. Is it? I was saying (or thought I was saying): "Here are two doctors whose work I know and trust." Reducing that to dollars and cents makes it something else, something less.

What it actually does is to reduce my professional opinion to shopping advice, which is in fact exactly what market-based incentives are supposed to do.

I thought of this push for cost consciousness a few months ago, when my wife had back surgery. We got several opinions: Laminectomy? Laminectomy with fusion? Even when surgeons at different hospitals recommended the same procedure, we did not ask what reimbursement rate the respective institution had negotiated with our insurer. (There are, of course, big differences, based not on quality – whatever that is – but on each hospital network’s market clout.)

The surgeon we picked arranged for several preoperative visits. At one of them the nurse said my wife would need a CT scan. We went right up one floor, and she had it done.

But should we have? There had already been an MRI. Was a CT scan really needed? And if it was, would we get the best price upstairs, or maybe across town?

Did my wife know? As a dermatologist, did I? Of course not. What would it have meant for us to say, "Hold on now, we’ve got skin in this game. We’d like to know why you need a CT scan. Is it really necessary? Is this the most cost-effective place to do it?"

Would that have been a shopping question, or a professional challenge? What would my friend’s hand surgeon have said if she asked him for a quote, or brought in one from another surgeon? Is buying surgery similar to bringing in a competitor’s coupon to Wal-Mart, or scanning a bookstore’s barcode on the Amazon app to see if they can match or beat it?

The powers shaping health care are not likely to be moved by such questions. They will point out – correctly – that medical costs are out of control, and therefore something must be done. They will therefore do something, as they are doing with electronic health records and will shortly do with ICD-10. The consequences of all these actions, intended and otherwise, remain to be seen both to doctors as providers and to all of us as consumers.

In the meantime, I have downloaded a discount coupon from the web: 10% off on any cystoscopy, but only if I act now and bring along 10 friends.

Let’s go, guys!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at at [email protected].

My friend had a cyst removed from the end of her right fourth finger. She told me that it’s healing well and she’s happy with the doctor’s work.

"Who removed it?" I asked her.

She gave me the name of a hand surgeon at a local teaching hospital.

"Did you compare alternatives for cost?" I asked her.

She had gotten another surgical opinion, but didn’t really understand my question about cost comparison. My friend is a retired attorney who knows me well enough to realize I’m not always totally serious.

I told her about the current thrust to make consumers (i.e., patients) more cost conscious by giving them "more skin in the game" (making it worth their while to get the best deal they can, as they would when, say, buying a flat-screen TV).

When I explained to my friend what I meant, she told me she wasn’t sure how well that would work. I told her that although I have skin in the skin game, I’m not so sure either.

Changes are in the wind. I got an e-mail the other day from a patient whose leg I had recently biopsied. I had told him that the result showed a fairly large basal cell and recommended excision, suggesting either of two surgeons.

His answer was: "Thanks. I will compare their costs and let you know which one I pick."

I responded that doing that would be fine, but might be complicated by the fact that one of the surgeons does Mohs, so to compare prices he would need to consult that doctor first and find out which technique he would use.

Perhaps I shouldn’t have been put off by his e-mail, but I was. It seemed to imply that a professional recommendation is on the same plane as advice about picking a lawn mower. Is it? I was saying (or thought I was saying): "Here are two doctors whose work I know and trust." Reducing that to dollars and cents makes it something else, something less.

What it actually does is to reduce my professional opinion to shopping advice, which is in fact exactly what market-based incentives are supposed to do.

I thought of this push for cost consciousness a few months ago, when my wife had back surgery. We got several opinions: Laminectomy? Laminectomy with fusion? Even when surgeons at different hospitals recommended the same procedure, we did not ask what reimbursement rate the respective institution had negotiated with our insurer. (There are, of course, big differences, based not on quality – whatever that is – but on each hospital network’s market clout.)

The surgeon we picked arranged for several preoperative visits. At one of them the nurse said my wife would need a CT scan. We went right up one floor, and she had it done.

But should we have? There had already been an MRI. Was a CT scan really needed? And if it was, would we get the best price upstairs, or maybe across town?

Did my wife know? As a dermatologist, did I? Of course not. What would it have meant for us to say, "Hold on now, we’ve got skin in this game. We’d like to know why you need a CT scan. Is it really necessary? Is this the most cost-effective place to do it?"

Would that have been a shopping question, or a professional challenge? What would my friend’s hand surgeon have said if she asked him for a quote, or brought in one from another surgeon? Is buying surgery similar to bringing in a competitor’s coupon to Wal-Mart, or scanning a bookstore’s barcode on the Amazon app to see if they can match or beat it?

The powers shaping health care are not likely to be moved by such questions. They will point out – correctly – that medical costs are out of control, and therefore something must be done. They will therefore do something, as they are doing with electronic health records and will shortly do with ICD-10. The consequences of all these actions, intended and otherwise, remain to be seen both to doctors as providers and to all of us as consumers.

In the meantime, I have downloaded a discount coupon from the web: 10% off on any cystoscopy, but only if I act now and bring along 10 friends.

Let’s go, guys!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at at [email protected].

My friend had a cyst removed from the end of her right fourth finger. She told me that it’s healing well and she’s happy with the doctor’s work.

"Who removed it?" I asked her.

She gave me the name of a hand surgeon at a local teaching hospital.

"Did you compare alternatives for cost?" I asked her.

She had gotten another surgical opinion, but didn’t really understand my question about cost comparison. My friend is a retired attorney who knows me well enough to realize I’m not always totally serious.

I told her about the current thrust to make consumers (i.e., patients) more cost conscious by giving them "more skin in the game" (making it worth their while to get the best deal they can, as they would when, say, buying a flat-screen TV).

When I explained to my friend what I meant, she told me she wasn’t sure how well that would work. I told her that although I have skin in the skin game, I’m not so sure either.

Changes are in the wind. I got an e-mail the other day from a patient whose leg I had recently biopsied. I had told him that the result showed a fairly large basal cell and recommended excision, suggesting either of two surgeons.

His answer was: "Thanks. I will compare their costs and let you know which one I pick."

I responded that doing that would be fine, but might be complicated by the fact that one of the surgeons does Mohs, so to compare prices he would need to consult that doctor first and find out which technique he would use.

Perhaps I shouldn’t have been put off by his e-mail, but I was. It seemed to imply that a professional recommendation is on the same plane as advice about picking a lawn mower. Is it? I was saying (or thought I was saying): "Here are two doctors whose work I know and trust." Reducing that to dollars and cents makes it something else, something less.

What it actually does is to reduce my professional opinion to shopping advice, which is in fact exactly what market-based incentives are supposed to do.

I thought of this push for cost consciousness a few months ago, when my wife had back surgery. We got several opinions: Laminectomy? Laminectomy with fusion? Even when surgeons at different hospitals recommended the same procedure, we did not ask what reimbursement rate the respective institution had negotiated with our insurer. (There are, of course, big differences, based not on quality – whatever that is – but on each hospital network’s market clout.)

The surgeon we picked arranged for several preoperative visits. At one of them the nurse said my wife would need a CT scan. We went right up one floor, and she had it done.

But should we have? There had already been an MRI. Was a CT scan really needed? And if it was, would we get the best price upstairs, or maybe across town?

Did my wife know? As a dermatologist, did I? Of course not. What would it have meant for us to say, "Hold on now, we’ve got skin in this game. We’d like to know why you need a CT scan. Is it really necessary? Is this the most cost-effective place to do it?"

Would that have been a shopping question, or a professional challenge? What would my friend’s hand surgeon have said if she asked him for a quote, or brought in one from another surgeon? Is buying surgery similar to bringing in a competitor’s coupon to Wal-Mart, or scanning a bookstore’s barcode on the Amazon app to see if they can match or beat it?

The powers shaping health care are not likely to be moved by such questions. They will point out – correctly – that medical costs are out of control, and therefore something must be done. They will therefore do something, as they are doing with electronic health records and will shortly do with ICD-10. The consequences of all these actions, intended and otherwise, remain to be seen both to doctors as providers and to all of us as consumers.

In the meantime, I have downloaded a discount coupon from the web: 10% off on any cystoscopy, but only if I act now and bring along 10 friends.

Let’s go, guys!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at at [email protected].

When my wife was hospitalized for back surgery, I learned more about the new information revolution in health care that provides formerly unattainable precision. This investigative report includes suggestions for how we, in the outpatient world, can implement these advances.

At a 3-hour preop marathon, my wife was interviewed by several people, including two nurses. The neurosurgery nurse practitioner asked my wife how much pain she was experiencing.

"It depends on my position," my wife answered. "If I’m sitting, it’s not that painful."

"But when it does hurt?"

"Well, it isn’t that bad."

"On a scale of 1-10?"

"Four."

Later on the anesthesia nurse asked her many questions. One was, "How much pain are you in, on a scale of 1-10?"

"It depends," began my wife, a slow learner.

"On a scale of 1-10?"

"Four."

Things went smoothly after that until the final question, "Do you feel safe at home?"

I had kept my mouth shut until then, but at that point, I got clarification that she was, indeed, asking whether my wife feared being abused after discharge. Not an unfair question, though I did wonder whether someone who really wanted to know would ask the question while a potential abuser looked on.

On the morning of surgery a clerk asked my wife again how much pain she was in, on a scale of one 1-10. In the recovery room they asked her again, several times.

Once my wife reached the ward, each nurse asked, once per shift, how much pain she had, on a scale of 1-10. At first, she tried to explain through her opiate stupor, what she was feeling.

"On a scale of 1-10," came the polite but insistent request. I doubt whether my wife remembered 5 minutes later what number she had given, which had in any case been duly noted and entered into the computer.

Ditto the aides. Ditto the physical therapist. Ditto the occupational therapist. At each visit.

Back home the visiting nurse’s aid called to visit and set up services. Before the nurse came, I said to my wife, "Let’s practice."

"Practice what?"

"Saying ‘four’ "

"Why four?"

"Because she’s going to ask you how much pain you’re having, on a scale of 1-10."

"But it isn’t four."

"Okay, say three."

The nurse came. Her first question was, "How much pain are you having, on a scale of 1-10?"

My wife tried again to give a nuanced answer. But eventually she did say, "Four."

The nurse asked my wife whether she was depressed. "Starting last month, they’re making us ask that."

My wife laughed. "I feel wonderful!" she said. "I don’t look depressed, do I?"

"I need a ‘yes’ or ‘no,’ " said the nurse.

"No," said my wife.

"Thank you," said the nurse, wearily. "I have a 30-page form to fill out for every case."

All of the "yes" and "no" replies, and all the numbers from 1-10, will be recorded and filed in the great information repository in the sky.

We can easily apply this method to our own practices.

Consider:

"Mr. Smith, how is your eczema?"

"Doing better, Doc, thanks."

"Great. How much does it itch, on a scale of 1-10?"

"Well, it’s worse at night."

"On a scale of 1-10, please."

"At night, or when I’m working?"

"On a scale of 1-10."

"Two."

"Excellent. How regular have you been with the application?"

"Pretty regular."

"On a scale of 1-10."

"What?"

"How happy are you with the service you received in this office?"

"Well, pretty happy, I guess."

"On a scale of 1-5, with five being ‘Very happy.’  "

"I suppose three."

"How likely are you to use our services again, or to refer a friend, on a scale of 1-6, with six being, ‘You bet!’ and one being, ‘No way, Jose!’?"

"Look, I think that’s enough."

"Just a few more questions, Mr. Smith. Mr. Smith, why are you staring at me like that? Mr. Smith, please get your hands off my neck. What? How much ... do I want ... you to stop ... throttling me? A lot! What? On a scale of 1-10? 10! 10!"

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my wife was hospitalized for back surgery, I learned more about the new information revolution in health care that provides formerly unattainable precision. This investigative report includes suggestions for how we, in the outpatient world, can implement these advances.

At a 3-hour preop marathon, my wife was interviewed by several people, including two nurses. The neurosurgery nurse practitioner asked my wife how much pain she was experiencing.

"It depends on my position," my wife answered. "If I’m sitting, it’s not that painful."

"But when it does hurt?"

"Well, it isn’t that bad."

"On a scale of 1-10?"

"Four."

Later on the anesthesia nurse asked her many questions. One was, "How much pain are you in, on a scale of 1-10?"

"It depends," began my wife, a slow learner.

"On a scale of 1-10?"

"Four."

Things went smoothly after that until the final question, "Do you feel safe at home?"

I had kept my mouth shut until then, but at that point, I got clarification that she was, indeed, asking whether my wife feared being abused after discharge. Not an unfair question, though I did wonder whether someone who really wanted to know would ask the question while a potential abuser looked on.

On the morning of surgery a clerk asked my wife again how much pain she was in, on a scale of one 1-10. In the recovery room they asked her again, several times.

Once my wife reached the ward, each nurse asked, once per shift, how much pain she had, on a scale of 1-10. At first, she tried to explain through her opiate stupor, what she was feeling.

"On a scale of 1-10," came the polite but insistent request. I doubt whether my wife remembered 5 minutes later what number she had given, which had in any case been duly noted and entered into the computer.

Ditto the aides. Ditto the physical therapist. Ditto the occupational therapist. At each visit.

Back home the visiting nurse’s aid called to visit and set up services. Before the nurse came, I said to my wife, "Let’s practice."

"Practice what?"

"Saying ‘four’ "

"Why four?"

"Because she’s going to ask you how much pain you’re having, on a scale of 1-10."

"But it isn’t four."

"Okay, say three."

The nurse came. Her first question was, "How much pain are you having, on a scale of 1-10?"

My wife tried again to give a nuanced answer. But eventually she did say, "Four."

The nurse asked my wife whether she was depressed. "Starting last month, they’re making us ask that."

My wife laughed. "I feel wonderful!" she said. "I don’t look depressed, do I?"

"I need a ‘yes’ or ‘no,’ " said the nurse.

"No," said my wife.

"Thank you," said the nurse, wearily. "I have a 30-page form to fill out for every case."

All of the "yes" and "no" replies, and all the numbers from 1-10, will be recorded and filed in the great information repository in the sky.

We can easily apply this method to our own practices.

Consider:

"Mr. Smith, how is your eczema?"

"Doing better, Doc, thanks."

"Great. How much does it itch, on a scale of 1-10?"

"Well, it’s worse at night."

"On a scale of 1-10, please."

"At night, or when I’m working?"

"On a scale of 1-10."

"Two."

"Excellent. How regular have you been with the application?"

"Pretty regular."

"On a scale of 1-10."

"What?"

"How happy are you with the service you received in this office?"

"Well, pretty happy, I guess."

"On a scale of 1-5, with five being ‘Very happy.’  "

"I suppose three."

"How likely are you to use our services again, or to refer a friend, on a scale of 1-6, with six being, ‘You bet!’ and one being, ‘No way, Jose!’?"

"Look, I think that’s enough."

"Just a few more questions, Mr. Smith. Mr. Smith, why are you staring at me like that? Mr. Smith, please get your hands off my neck. What? How much ... do I want ... you to stop ... throttling me? A lot! What? On a scale of 1-10? 10! 10!"

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my wife was hospitalized for back surgery, I learned more about the new information revolution in health care that provides formerly unattainable precision. This investigative report includes suggestions for how we, in the outpatient world, can implement these advances.

At a 3-hour preop marathon, my wife was interviewed by several people, including two nurses. The neurosurgery nurse practitioner asked my wife how much pain she was experiencing.

"It depends on my position," my wife answered. "If I’m sitting, it’s not that painful."

"But when it does hurt?"

"Well, it isn’t that bad."

"On a scale of 1-10?"

"Four."

Later on the anesthesia nurse asked her many questions. One was, "How much pain are you in, on a scale of 1-10?"

"It depends," began my wife, a slow learner.

"On a scale of 1-10?"

"Four."

Things went smoothly after that until the final question, "Do you feel safe at home?"

I had kept my mouth shut until then, but at that point, I got clarification that she was, indeed, asking whether my wife feared being abused after discharge. Not an unfair question, though I did wonder whether someone who really wanted to know would ask the question while a potential abuser looked on.

On the morning of surgery a clerk asked my wife again how much pain she was in, on a scale of one 1-10. In the recovery room they asked her again, several times.

Once my wife reached the ward, each nurse asked, once per shift, how much pain she had, on a scale of 1-10. At first, she tried to explain through her opiate stupor, what she was feeling.

"On a scale of 1-10," came the polite but insistent request. I doubt whether my wife remembered 5 minutes later what number she had given, which had in any case been duly noted and entered into the computer.

Ditto the aides. Ditto the physical therapist. Ditto the occupational therapist. At each visit.

Back home the visiting nurse’s aid called to visit and set up services. Before the nurse came, I said to my wife, "Let’s practice."

"Practice what?"

"Saying ‘four’ "

"Why four?"

"Because she’s going to ask you how much pain you’re having, on a scale of 1-10."

"But it isn’t four."

"Okay, say three."

The nurse came. Her first question was, "How much pain are you having, on a scale of 1-10?"

My wife tried again to give a nuanced answer. But eventually she did say, "Four."

The nurse asked my wife whether she was depressed. "Starting last month, they’re making us ask that."

My wife laughed. "I feel wonderful!" she said. "I don’t look depressed, do I?"

"I need a ‘yes’ or ‘no,’ " said the nurse.

"No," said my wife.

"Thank you," said the nurse, wearily. "I have a 30-page form to fill out for every case."

All of the "yes" and "no" replies, and all the numbers from 1-10, will be recorded and filed in the great information repository in the sky.

We can easily apply this method to our own practices.

Consider:

"Mr. Smith, how is your eczema?"

"Doing better, Doc, thanks."

"Great. How much does it itch, on a scale of 1-10?"

"Well, it’s worse at night."

"On a scale of 1-10, please."

"At night, or when I’m working?"

"On a scale of 1-10."

"Two."

"Excellent. How regular have you been with the application?"

"Pretty regular."

"On a scale of 1-10."

"What?"

"How happy are you with the service you received in this office?"

"Well, pretty happy, I guess."

"On a scale of 1-5, with five being ‘Very happy.’  "

"I suppose three."

"How likely are you to use our services again, or to refer a friend, on a scale of 1-6, with six being, ‘You bet!’ and one being, ‘No way, Jose!’?"

"Look, I think that’s enough."

"Just a few more questions, Mr. Smith. Mr. Smith, why are you staring at me like that? Mr. Smith, please get your hands off my neck. What? How much ... do I want ... you to stop ... throttling me? A lot! What? On a scale of 1-10? 10! 10!"

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."

Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.

Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.

I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.

"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.

I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."

A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."

I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."

"No," said Victoria, "I wasn’t on the patch anymore."

"What?!" I exclaimed.

"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."

"Wasn’t there anyone else in her office who could refill it for you?" I asked.

"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."

I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.

And when she ran out of contraceptive patches, she didn’t get them refilled.

Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.

Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.

The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.

Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.

After all, we have them ourselves.

Dr. Rockoff practices dermatology in Brookline, Mass. 

Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."

Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.

Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.

I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.

"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.

I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."

A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."

I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."

"No," said Victoria, "I wasn’t on the patch anymore."

"What?!" I exclaimed.

"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."

"Wasn’t there anyone else in her office who could refill it for you?" I asked.

"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."

I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.

And when she ran out of contraceptive patches, she didn’t get them refilled.

Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.

Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.

The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.

Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.

After all, we have them ourselves.

Dr. Rockoff practices dermatology in Brookline, Mass. 

Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."

Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.

Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.

I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.

"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.

I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."

A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."

I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."

"No," said Victoria, "I wasn’t on the patch anymore."

"What?!" I exclaimed.

"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."

"Wasn’t there anyone else in her office who could refill it for you?" I asked.

"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."

I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.

And when she ran out of contraceptive patches, she didn’t get them refilled.

Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.

Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.

The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.

Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.

After all, we have them ourselves.

Dr. Rockoff practices dermatology in Brookline, Mass.