Under My Skin

I asked a new acquaintance what he does for a living.

"We make call center software," he said. "When you hear, ‘This call may be monitored or recorded for quality and training purposes,’ – that’s us."

"How do you monitor quality?" I asked.

He ticked off several measures: efficiency, productivity, courtesy, and so forth. "All employees get a report card every day, showing where they stand on several parameters, such as how many problems they were able to solve; how long it took; and how many times they interrupted the caller."

"So your quality-control software helps them do their job better," I said.

"Of course," he replied. "If they’re falling short, they meet with a supervisor who reviews calls with them in person, step-by-step, so they see what they need to work on."

That sounds sensible enough. It stands in stark contrast to the way we are measured.

I’ve previously written about how some insurance companies have rated me Tier I (hooray!), then how one of them demoted me to Tier II (the shame!), saddling their patients with a higher copay for choosing a less-efficient, lower-quality doctor like me. I described my Kafkaesque experience trying to learn the charges against me and my futile efforts to overturn or even understand them.

Then last month, I got this year’s rating from one of the insurers – still Tier I (hooray!). Showing either that I really persevere or that I refuse to learn from experience, I wrote the medical director who had signed this latest report card:

Thank you for my grade. Could you please help me understand two criteria on which I seem to have excelled: 1) "fungal infection w/o surgery" and 2) "skin cancer, major, w/o surgery." Is there a fungal infection w/ surgery? Should there be a major skin cancer w/o surgery? Thanks so much.

To my gratified astonishment, he actually called me!

I thanked him for his responsiveness. "The company that developed our software to measure quality and efficiency sold out to another company," he said, "which is now being run by a third firm. But the methodology is very robust." In other words, he had no idea what the numbers meant either.

"As to the two episode treatment groups you questioned," he went on, "a diabetic with actinomycosis may need amputation. ‘Fungal infection without surgery’ would refer to less severe fungi. As to ‘skin cancers, without surgery,’ that just means you performed a biopsy or simple excision, not Mohs or reconstructive surgery."

I thanked him for the clarification, but pressed on. "For fungal infections," I said, "I make a diagnosis and prescribe a generic cream or, occasionally, prescribe an oral treatment. I rarely do a KOH [potassium hydroxide] prep, and in any case don’t bill for it because it’s not covered. Once in a great while I send a nail biopsy or, even more rarely, a culture. As for skin cancers, I do a biopsy to make the diagnosis, and then either perform a simple removal or send the patient elsewhere.

"If I wanted to improve my performance," I concluded, "how much less could I do?" He had no answer.

"I’m happy you rated me Tier I," I said, "though another insurer rated me Tier II on the basis of the same data. When I asked to see those data, they sent me a spreadsheet with 4,700 rows, half with missing demographics, and 27 columns, each with indecipherable acronyms. Can you honestly tell me that my report card gives me what I need to become a better doctor?" Again, he had no answer.

"I’ll tell you what I think," I went on, "You don’t send these reports to improve doctors’ performance, which they obviously can’t. You send them so you can tell your investors, your regulators, and possibly yourselves that you are doing something useful to improve medical quality and efficiency, when in fact you’re engaged in an empty ritual that does nothing of the kind." For a third time, he said nothing.

I thanked him again for his courtesy and hung up.

My little speech will have no impact, but it felt good. If my call center friend’s software doesn’t produce results, his firm will lose sales, revenue, and market share. He, therefore, has to make a product that delivers.

I asked a new acquaintance what he does for a living.

"We make call center software," he said. "When you hear, ‘This call may be monitored or recorded for quality and training purposes,’ – that’s us."

"How do you monitor quality?" I asked.

He ticked off several measures: efficiency, productivity, courtesy, and so forth. "All employees get a report card every day, showing where they stand on several parameters, such as how many problems they were able to solve; how long it took; and how many times they interrupted the caller."

"So your quality-control software helps them do their job better," I said.

"Of course," he replied. "If they’re falling short, they meet with a supervisor who reviews calls with them in person, step-by-step, so they see what they need to work on."

That sounds sensible enough. It stands in stark contrast to the way we are measured.

I’ve previously written about how some insurance companies have rated me Tier I (hooray!), then how one of them demoted me to Tier II (the shame!), saddling their patients with a higher copay for choosing a less-efficient, lower-quality doctor like me. I described my Kafkaesque experience trying to learn the charges against me and my futile efforts to overturn or even understand them.

Then last month, I got this year’s rating from one of the insurers – still Tier I (hooray!). Showing either that I really persevere or that I refuse to learn from experience, I wrote the medical director who had signed this latest report card:

Thank you for my grade. Could you please help me understand two criteria on which I seem to have excelled: 1) "fungal infection w/o surgery" and 2) "skin cancer, major, w/o surgery." Is there a fungal infection w/ surgery? Should there be a major skin cancer w/o surgery? Thanks so much.

To my gratified astonishment, he actually called me!

I thanked him for his responsiveness. "The company that developed our software to measure quality and efficiency sold out to another company," he said, "which is now being run by a third firm. But the methodology is very robust." In other words, he had no idea what the numbers meant either.

"As to the two episode treatment groups you questioned," he went on, "a diabetic with actinomycosis may need amputation. ‘Fungal infection without surgery’ would refer to less severe fungi. As to ‘skin cancers, without surgery,’ that just means you performed a biopsy or simple excision, not Mohs or reconstructive surgery."

I thanked him for the clarification, but pressed on. "For fungal infections," I said, "I make a diagnosis and prescribe a generic cream or, occasionally, prescribe an oral treatment. I rarely do a KOH [potassium hydroxide] prep, and in any case don’t bill for it because it’s not covered. Once in a great while I send a nail biopsy or, even more rarely, a culture. As for skin cancers, I do a biopsy to make the diagnosis, and then either perform a simple removal or send the patient elsewhere.

"If I wanted to improve my performance," I concluded, "how much less could I do?" He had no answer.

"I’m happy you rated me Tier I," I said, "though another insurer rated me Tier II on the basis of the same data. When I asked to see those data, they sent me a spreadsheet with 4,700 rows, half with missing demographics, and 27 columns, each with indecipherable acronyms. Can you honestly tell me that my report card gives me what I need to become a better doctor?" Again, he had no answer.

"I’ll tell you what I think," I went on, "You don’t send these reports to improve doctors’ performance, which they obviously can’t. You send them so you can tell your investors, your regulators, and possibly yourselves that you are doing something useful to improve medical quality and efficiency, when in fact you’re engaged in an empty ritual that does nothing of the kind." For a third time, he said nothing.

I thanked him again for his courtesy and hung up.

My little speech will have no impact, but it felt good. If my call center friend’s software doesn’t produce results, his firm will lose sales, revenue, and market share. He, therefore, has to make a product that delivers.

I asked a new acquaintance what he does for a living.

"We make call center software," he said. "When you hear, ‘This call may be monitored or recorded for quality and training purposes,’ – that’s us."

"How do you monitor quality?" I asked.

He ticked off several measures: efficiency, productivity, courtesy, and so forth. "All employees get a report card every day, showing where they stand on several parameters, such as how many problems they were able to solve; how long it took; and how many times they interrupted the caller."

"So your quality-control software helps them do their job better," I said.

"Of course," he replied. "If they’re falling short, they meet with a supervisor who reviews calls with them in person, step-by-step, so they see what they need to work on."

That sounds sensible enough. It stands in stark contrast to the way we are measured.

I’ve previously written about how some insurance companies have rated me Tier I (hooray!), then how one of them demoted me to Tier II (the shame!), saddling their patients with a higher copay for choosing a less-efficient, lower-quality doctor like me. I described my Kafkaesque experience trying to learn the charges against me and my futile efforts to overturn or even understand them.

Then last month, I got this year’s rating from one of the insurers – still Tier I (hooray!). Showing either that I really persevere or that I refuse to learn from experience, I wrote the medical director who had signed this latest report card:

Thank you for my grade. Could you please help me understand two criteria on which I seem to have excelled: 1) "fungal infection w/o surgery" and 2) "skin cancer, major, w/o surgery." Is there a fungal infection w/ surgery? Should there be a major skin cancer w/o surgery? Thanks so much.

To my gratified astonishment, he actually called me!

I thanked him for his responsiveness. "The company that developed our software to measure quality and efficiency sold out to another company," he said, "which is now being run by a third firm. But the methodology is very robust." In other words, he had no idea what the numbers meant either.

"As to the two episode treatment groups you questioned," he went on, "a diabetic with actinomycosis may need amputation. ‘Fungal infection without surgery’ would refer to less severe fungi. As to ‘skin cancers, without surgery,’ that just means you performed a biopsy or simple excision, not Mohs or reconstructive surgery."

I thanked him for the clarification, but pressed on. "For fungal infections," I said, "I make a diagnosis and prescribe a generic cream or, occasionally, prescribe an oral treatment. I rarely do a KOH [potassium hydroxide] prep, and in any case don’t bill for it because it’s not covered. Once in a great while I send a nail biopsy or, even more rarely, a culture. As for skin cancers, I do a biopsy to make the diagnosis, and then either perform a simple removal or send the patient elsewhere.

"If I wanted to improve my performance," I concluded, "how much less could I do?" He had no answer.

"I’m happy you rated me Tier I," I said, "though another insurer rated me Tier II on the basis of the same data. When I asked to see those data, they sent me a spreadsheet with 4,700 rows, half with missing demographics, and 27 columns, each with indecipherable acronyms. Can you honestly tell me that my report card gives me what I need to become a better doctor?" Again, he had no answer.

"I’ll tell you what I think," I went on, "You don’t send these reports to improve doctors’ performance, which they obviously can’t. You send them so you can tell your investors, your regulators, and possibly yourselves that you are doing something useful to improve medical quality and efficiency, when in fact you’re engaged in an empty ritual that does nothing of the kind." For a third time, he said nothing.

I thanked him again for his courtesy and hung up.

My little speech will have no impact, but it felt good. If my call center friend’s software doesn’t produce results, his firm will lose sales, revenue, and market share. He, therefore, has to make a product that delivers.

My office had an unofficial record that stood for years – The Most Lost Patients. (The Guinness World Records never includes this one.) But records are made to be broken.

A long time ago, a woman came in late one afternoon. Her responses seemed somehow off, until she brightened and said, "Wait, you’re not Dr. Brownton!"

I checked the name on my lab coat. "You’re right," I said. "I’m not. Dr. Brownton is across the street and down a block to the left."

"That explains why you took me early," she said. "I’m going to come to you from now on."

But she didn’t. She probably set out for my office and ended up by mistake back at Dr. Brownton’s office, across the street and down a block.

That record stood long and untouchable until 3 years ago, when a man showed up with a complaint of, "I want Lasik surgery."

"But I’m a dermatologist," I observed.

"Doesn’t the sign on your door say Boston Eye Associates?" he replied.

I thought to myself, "Before you get Lasik, you might look into spectacles." Instead, I told him that Boston Eye Associates was five floors up. I also noted that he had periocular eczema and prescribed accordingly. Later, I learned from my ophthalmology neighbors, that he never went through with the Lasik. So, in a sense, he had come to the right place after all, though for the wrong reasons.

That record, unassailable as it seemed, stood for just 3 years, until last week, when a man came with an even more curious complaint: "I have a high PSA." There followed some dialogue I wanted to channel to Eugene Ionesco, who could have used it.

Me: Are you sure you’re at the right doctor?

Man: I have a high PSA.

Me: But I’m a skin doctor.

Man: Dr. Wong asked me to visit you.

Me: I’m sure he did, but PSA refers to the prostate. You need a urologist.

Man: (checking referral note) It says your name right here.

Me: Do you have a problem on your skin?

Man: (brightens, rolling up left pant leg) Yes!

Me: (Points to Man’s shin) You have eczema, right there, see? (Man nods.) I will give you a cream for it. (Hands Man prescription.)

Man: (Takes prescription.) Thank you.

Me: You should call Dr. Wong to ask which doctor he wants you to see about the PSA.

Man: I will! Thank you! (Lights fade to black. Curtain.)

I can’t even imagine what’s going to top that. (A woman here for her 6-month ultrasound?) But records are made to be broken. After the Babe, eventually there was Maris, and then the Steroid Boys.

So who knows? Maybe I’ll get a TV series some day, "Lost: Dermatology Edition."

My office had an unofficial record that stood for years – The Most Lost Patients. (The Guinness World Records never includes this one.) But records are made to be broken.

A long time ago, a woman came in late one afternoon. Her responses seemed somehow off, until she brightened and said, "Wait, you’re not Dr. Brownton!"

I checked the name on my lab coat. "You’re right," I said. "I’m not. Dr. Brownton is across the street and down a block to the left."

"That explains why you took me early," she said. "I’m going to come to you from now on."

But she didn’t. She probably set out for my office and ended up by mistake back at Dr. Brownton’s office, across the street and down a block.

That record stood long and untouchable until 3 years ago, when a man showed up with a complaint of, "I want Lasik surgery."

"But I’m a dermatologist," I observed.

"Doesn’t the sign on your door say Boston Eye Associates?" he replied.

I thought to myself, "Before you get Lasik, you might look into spectacles." Instead, I told him that Boston Eye Associates was five floors up. I also noted that he had periocular eczema and prescribed accordingly. Later, I learned from my ophthalmology neighbors, that he never went through with the Lasik. So, in a sense, he had come to the right place after all, though for the wrong reasons.

That record, unassailable as it seemed, stood for just 3 years, until last week, when a man came with an even more curious complaint: "I have a high PSA." There followed some dialogue I wanted to channel to Eugene Ionesco, who could have used it.

Me: Are you sure you’re at the right doctor?

Man: I have a high PSA.

Me: But I’m a skin doctor.

Man: Dr. Wong asked me to visit you.

Me: I’m sure he did, but PSA refers to the prostate. You need a urologist.

Man: (checking referral note) It says your name right here.

Me: Do you have a problem on your skin?

Man: (brightens, rolling up left pant leg) Yes!

Me: (Points to Man’s shin) You have eczema, right there, see? (Man nods.) I will give you a cream for it. (Hands Man prescription.)

Man: (Takes prescription.) Thank you.

Me: You should call Dr. Wong to ask which doctor he wants you to see about the PSA.

Man: I will! Thank you! (Lights fade to black. Curtain.)

I can’t even imagine what’s going to top that. (A woman here for her 6-month ultrasound?) But records are made to be broken. After the Babe, eventually there was Maris, and then the Steroid Boys.

So who knows? Maybe I’ll get a TV series some day, "Lost: Dermatology Edition."

My office had an unofficial record that stood for years – The Most Lost Patients. (The Guinness World Records never includes this one.) But records are made to be broken.

A long time ago, a woman came in late one afternoon. Her responses seemed somehow off, until she brightened and said, "Wait, you’re not Dr. Brownton!"

I checked the name on my lab coat. "You’re right," I said. "I’m not. Dr. Brownton is across the street and down a block to the left."

"That explains why you took me early," she said. "I’m going to come to you from now on."

But she didn’t. She probably set out for my office and ended up by mistake back at Dr. Brownton’s office, across the street and down a block.

That record stood long and untouchable until 3 years ago, when a man showed up with a complaint of, "I want Lasik surgery."

"But I’m a dermatologist," I observed.

"Doesn’t the sign on your door say Boston Eye Associates?" he replied.

I thought to myself, "Before you get Lasik, you might look into spectacles." Instead, I told him that Boston Eye Associates was five floors up. I also noted that he had periocular eczema and prescribed accordingly. Later, I learned from my ophthalmology neighbors, that he never went through with the Lasik. So, in a sense, he had come to the right place after all, though for the wrong reasons.

That record, unassailable as it seemed, stood for just 3 years, until last week, when a man came with an even more curious complaint: "I have a high PSA." There followed some dialogue I wanted to channel to Eugene Ionesco, who could have used it.

Me: Are you sure you’re at the right doctor?

Man: I have a high PSA.

Me: But I’m a skin doctor.

Man: Dr. Wong asked me to visit you.

Me: I’m sure he did, but PSA refers to the prostate. You need a urologist.

Man: (checking referral note) It says your name right here.

Me: Do you have a problem on your skin?

Man: (brightens, rolling up left pant leg) Yes!

Me: (Points to Man’s shin) You have eczema, right there, see? (Man nods.) I will give you a cream for it. (Hands Man prescription.)

Man: (Takes prescription.) Thank you.

Me: You should call Dr. Wong to ask which doctor he wants you to see about the PSA.

Man: I will! Thank you! (Lights fade to black. Curtain.)

I can’t even imagine what’s going to top that. (A woman here for her 6-month ultrasound?) But records are made to be broken. After the Babe, eventually there was Maris, and then the Steroid Boys.

So who knows? Maybe I’ll get a TV series some day, "Lost: Dermatology Edition."

"I’ve had a poison ivy website for 10 years," read the e-mail from someone I didn’t know, named Jack, "and I wondered if you might be interested in answering some questions about that skin condition."

"Sure," I sent back. "How’d you get my name?"

"I asked my internist Stan if he knew a dermatologist with a sense of humor."

We arranged to talk on the phone. Jack told me he designs websites for a living and is, like me, an expat New Yorker. "People send me anecdotes and photos for my website," he said. "I have a Poison Ivy Hall of Fame. Some of the pictures are pretty impressive."

Jack had read books on poison ivy and looked at online health information websites. "How did you get involved with this?" I asked him.

"I had a bad case myself," said Jack. "Then I talked to people and collected stories. I guess you could say I fell into poison ivy."

I knew we would get along fine.

Jack set a time to come to my office for a video session, during which I would respond to common questions he gets. His list was familiar, because patients ask us the same ones: What’s in the blisters? Can you spread it by scratching? And so forth.

I expected the session to be cordial, but in truth I had doubts. After all, here was an energetic layman who had run a health-related website for 10 years – one that gets thousands of hits a week in winter and a hundred thousand in summer – and who had never once spoken to a doctor about the subject. Why?

Some lay groups treat our profession with suspicion, even hostility. I think for instance of the Morgellons folks. They are convinced that their sufferers are afflicted by unknown fibers, perhaps originating in outer space. Doctors like us tend to suggest, however gently, that the itching and burning sensations they report have a psychiatric origin. To them, this just goes to show how insensitive and indifferent we are.

A few years ago I wrote to the Morgellons organization. Since many of their cases seem to cluster in the Boston area, I offered to examine patients, perform biopsies, and so forth, for free. My letter was neutral, expressing no skepticism. They ignored my offer.

More recently, the Morgellons lobby convinced the Centers for Disease Control and Prevention to research the condition. Some $600,000 later, their study found much picking and scratching, no infectious or environmental cause, and no alien fibers, just cellulose. This report will no doubt fail to convince anyone not already convinced.

I considered that some opinions I would be sharing with Jack might clash with beliefs that are widespread in the poison ivy community. (There is one, just as there is a ChapStick addiction community, and a rename-yourself-after-a-Mayan-deity community.) I would not agree, for instance, that oozing contact dermatitis implies infection, that blister fluid contains poison, or that poison ivy itches in a unique way that differs from all other itches. Also, I would remain politely agnostic on the efficacy of jewelweed and myriad other natural and folk remedies. Would my opinions be acceptable? Tolerable?

I needn’t have worried. Jack was pleasant and willing to listen, even when what I said surprised him. Key, of course, was Jack’s sense of humor. As anyone who deals with a lot of people knows, a parley with the humorless can be tough.

But if Jack is neither suspicious nor hostile, why didn’t he talk to a doctor for a decade? Probably for the boring but key reason that he just didn’t know anyone to talk to. And how come the 100,000 people who visited his website weren’t bothered by the absence of an authorized medical voice? Because while we may flatter ourselves that people shouldn’t get information anyway they can, they do. At times – pretty often, in fact – they give little or no extra weight to pronouncements from official authorities.

If Jack follows through and posts the edited video (he promised the camera would not make me look fat), then I will have possibly diluted a little of the copious folklore about urushiol dermatitis. But not much.

But it was fun falling into poison ivy myself. So to speak.

"I’ve had a poison ivy website for 10 years," read the e-mail from someone I didn’t know, named Jack, "and I wondered if you might be interested in answering some questions about that skin condition."

"Sure," I sent back. "How’d you get my name?"

"I asked my internist Stan if he knew a dermatologist with a sense of humor."

We arranged to talk on the phone. Jack told me he designs websites for a living and is, like me, an expat New Yorker. "People send me anecdotes and photos for my website," he said. "I have a Poison Ivy Hall of Fame. Some of the pictures are pretty impressive."

Jack had read books on poison ivy and looked at online health information websites. "How did you get involved with this?" I asked him.

"I had a bad case myself," said Jack. "Then I talked to people and collected stories. I guess you could say I fell into poison ivy."

I knew we would get along fine.

Jack set a time to come to my office for a video session, during which I would respond to common questions he gets. His list was familiar, because patients ask us the same ones: What’s in the blisters? Can you spread it by scratching? And so forth.

I expected the session to be cordial, but in truth I had doubts. After all, here was an energetic layman who had run a health-related website for 10 years – one that gets thousands of hits a week in winter and a hundred thousand in summer – and who had never once spoken to a doctor about the subject. Why?

Some lay groups treat our profession with suspicion, even hostility. I think for instance of the Morgellons folks. They are convinced that their sufferers are afflicted by unknown fibers, perhaps originating in outer space. Doctors like us tend to suggest, however gently, that the itching and burning sensations they report have a psychiatric origin. To them, this just goes to show how insensitive and indifferent we are.

A few years ago I wrote to the Morgellons organization. Since many of their cases seem to cluster in the Boston area, I offered to examine patients, perform biopsies, and so forth, for free. My letter was neutral, expressing no skepticism. They ignored my offer.

More recently, the Morgellons lobby convinced the Centers for Disease Control and Prevention to research the condition. Some $600,000 later, their study found much picking and scratching, no infectious or environmental cause, and no alien fibers, just cellulose. This report will no doubt fail to convince anyone not already convinced.

I considered that some opinions I would be sharing with Jack might clash with beliefs that are widespread in the poison ivy community. (There is one, just as there is a ChapStick addiction community, and a rename-yourself-after-a-Mayan-deity community.) I would not agree, for instance, that oozing contact dermatitis implies infection, that blister fluid contains poison, or that poison ivy itches in a unique way that differs from all other itches. Also, I would remain politely agnostic on the efficacy of jewelweed and myriad other natural and folk remedies. Would my opinions be acceptable? Tolerable?

I needn’t have worried. Jack was pleasant and willing to listen, even when what I said surprised him. Key, of course, was Jack’s sense of humor. As anyone who deals with a lot of people knows, a parley with the humorless can be tough.

But if Jack is neither suspicious nor hostile, why didn’t he talk to a doctor for a decade? Probably for the boring but key reason that he just didn’t know anyone to talk to. And how come the 100,000 people who visited his website weren’t bothered by the absence of an authorized medical voice? Because while we may flatter ourselves that people shouldn’t get information anyway they can, they do. At times – pretty often, in fact – they give little or no extra weight to pronouncements from official authorities.

If Jack follows through and posts the edited video (he promised the camera would not make me look fat), then I will have possibly diluted a little of the copious folklore about urushiol dermatitis. But not much.

But it was fun falling into poison ivy myself. So to speak.

"I’ve had a poison ivy website for 10 years," read the e-mail from someone I didn’t know, named Jack, "and I wondered if you might be interested in answering some questions about that skin condition."

"Sure," I sent back. "How’d you get my name?"

"I asked my internist Stan if he knew a dermatologist with a sense of humor."

We arranged to talk on the phone. Jack told me he designs websites for a living and is, like me, an expat New Yorker. "People send me anecdotes and photos for my website," he said. "I have a Poison Ivy Hall of Fame. Some of the pictures are pretty impressive."

Jack had read books on poison ivy and looked at online health information websites. "How did you get involved with this?" I asked him.

"I had a bad case myself," said Jack. "Then I talked to people and collected stories. I guess you could say I fell into poison ivy."

I knew we would get along fine.

Jack set a time to come to my office for a video session, during which I would respond to common questions he gets. His list was familiar, because patients ask us the same ones: What’s in the blisters? Can you spread it by scratching? And so forth.

I expected the session to be cordial, but in truth I had doubts. After all, here was an energetic layman who had run a health-related website for 10 years – one that gets thousands of hits a week in winter and a hundred thousand in summer – and who had never once spoken to a doctor about the subject. Why?

Some lay groups treat our profession with suspicion, even hostility. I think for instance of the Morgellons folks. They are convinced that their sufferers are afflicted by unknown fibers, perhaps originating in outer space. Doctors like us tend to suggest, however gently, that the itching and burning sensations they report have a psychiatric origin. To them, this just goes to show how insensitive and indifferent we are.

A few years ago I wrote to the Morgellons organization. Since many of their cases seem to cluster in the Boston area, I offered to examine patients, perform biopsies, and so forth, for free. My letter was neutral, expressing no skepticism. They ignored my offer.

More recently, the Morgellons lobby convinced the Centers for Disease Control and Prevention to research the condition. Some $600,000 later, their study found much picking and scratching, no infectious or environmental cause, and no alien fibers, just cellulose. This report will no doubt fail to convince anyone not already convinced.

I considered that some opinions I would be sharing with Jack might clash with beliefs that are widespread in the poison ivy community. (There is one, just as there is a ChapStick addiction community, and a rename-yourself-after-a-Mayan-deity community.) I would not agree, for instance, that oozing contact dermatitis implies infection, that blister fluid contains poison, or that poison ivy itches in a unique way that differs from all other itches. Also, I would remain politely agnostic on the efficacy of jewelweed and myriad other natural and folk remedies. Would my opinions be acceptable? Tolerable?

I needn’t have worried. Jack was pleasant and willing to listen, even when what I said surprised him. Key, of course, was Jack’s sense of humor. As anyone who deals with a lot of people knows, a parley with the humorless can be tough.

But if Jack is neither suspicious nor hostile, why didn’t he talk to a doctor for a decade? Probably for the boring but key reason that he just didn’t know anyone to talk to. And how come the 100,000 people who visited his website weren’t bothered by the absence of an authorized medical voice? Because while we may flatter ourselves that people shouldn’t get information anyway they can, they do. At times – pretty often, in fact – they give little or no extra weight to pronouncements from official authorities.

If Jack follows through and posts the edited video (he promised the camera would not make me look fat), then I will have possibly diluted a little of the copious folklore about urushiol dermatitis. But not much.

But it was fun falling into poison ivy myself. So to speak.

A dermatologist’s office may not be the ideal site for family therapy, but it’s often a good place to see how close relatives interact, and even to influence their relationships a little. Many family combinations come into our offices: parents and children, husbands and wives, now and then even three generations in the same room.

Most kids and even teens don’t talk much. Asked why they’ve come, they shrug and look sideways, as if to say, "This wasn’t my idea – ask her." Once in a while, though, the child opens his or her mouth and speaks forcefully while Mom or Dad look on, probably an attorney-in-embryo or politician-in-training. Either way, the old folks probably have a tiger by the tail.

Most of the time, however, the parent does the talking while the child chafes in silence. What’s at stake is what is always in play between parents and children: control and autonomy. Mom is concerned; Junior rolls his eyes, wishing only to be left alone. Counseling in this context often calls for splitting the difference a little: letting the kid know he can eat pizza (Flash of triumph – "I told you, Ma!"), while encouraging the healthy diet that Mom feels is her probably futile but inescapable obligation to encourage. After exonerating soda and pizza, I often turn to the adolescent patient and add, "And always do your homework and listen to your mother." Mom always smiles. Sometimes the kid does, too.

Higher stakes call for greater finesse. One example is the adolescent with severe, cystic, scarring acne, whose parent has heard bad things about isotretinoin and just can’t come to terms with letting the child take it. Coming on strong is neither effective nor necessary. Delicately handled, most such tales have happy endings for both generations.

Sometimes when you meet a family you sense a particularly unhealthy dynamic. I think of the 5-year-old whose mother criticized her every time she moved. The little girl bit her lip and looked down, as her mother pronounced, "Doctor, she has to learn to behave properly." Seeing unhappiness develop before your eyes and being able to block it are very different things.

Often married couples come jointly, most of the time, but not always sharing the same exam room. Aspects of their relationship come right through: playful, tolerant, sometimes flat-out domineering. Watching a 75-year-old man treated like a child is not comfortable. ("Just show the doctor your back, will you?") At times, it’s the husband whose concerns about his wife’s scaly scalp or submammary keratoses are not shared by the spouse who actually has them.

In general, to be a long-married male is to be treated with well-meant and mostly-benign condescension. ("Doctor, he never uses sunscreen when we go to the beach. Tell him to use sunscreen.") I turn to the man and say, sternly, "Use sunscreen." But I put a wink in my voice. All of us understand each other.

Sometimes little kids are accompanied by both a parent and a grandparent. Contrary to the sentimental stereotype of grandma as a sagacious, even domineering matriarch, most grandparents in my office seem docile and deferential, even – or especially – the ones from an Old Country. Back in the house where language is no barrier, they may act differently, but somehow I doubt it. This is America, where youth brings wisdom, and e-mail is so last decade.

My favorite family visits are those of people married a very long time. Two months ago, I had on the same day not one but two couples, psychologically intact and living together, each pair married an astonishing 67 years.

I pointed to my student and said to one of the elderly women, who seemed especially sharp, "My young friend here is about to get married. Can you share with her any secrets of marital longevity?"

Without missing a beat, she said, "Deafness! He says, ‘Why?’ and I say ‘When?’ He says ‘What?’ and I say ‘Later.’ So we never argue."

I looked at her husband, who was smiling brightly. I don’t think he heard her.

A dermatologist’s office may not be the ideal site for family therapy, but it’s often a good place to see how close relatives interact, and even to influence their relationships a little. Many family combinations come into our offices: parents and children, husbands and wives, now and then even three generations in the same room.

Most kids and even teens don’t talk much. Asked why they’ve come, they shrug and look sideways, as if to say, "This wasn’t my idea – ask her." Once in a while, though, the child opens his or her mouth and speaks forcefully while Mom or Dad look on, probably an attorney-in-embryo or politician-in-training. Either way, the old folks probably have a tiger by the tail.

Most of the time, however, the parent does the talking while the child chafes in silence. What’s at stake is what is always in play between parents and children: control and autonomy. Mom is concerned; Junior rolls his eyes, wishing only to be left alone. Counseling in this context often calls for splitting the difference a little: letting the kid know he can eat pizza (Flash of triumph – "I told you, Ma!"), while encouraging the healthy diet that Mom feels is her probably futile but inescapable obligation to encourage. After exonerating soda and pizza, I often turn to the adolescent patient and add, "And always do your homework and listen to your mother." Mom always smiles. Sometimes the kid does, too.

Higher stakes call for greater finesse. One example is the adolescent with severe, cystic, scarring acne, whose parent has heard bad things about isotretinoin and just can’t come to terms with letting the child take it. Coming on strong is neither effective nor necessary. Delicately handled, most such tales have happy endings for both generations.

Sometimes when you meet a family you sense a particularly unhealthy dynamic. I think of the 5-year-old whose mother criticized her every time she moved. The little girl bit her lip and looked down, as her mother pronounced, "Doctor, she has to learn to behave properly." Seeing unhappiness develop before your eyes and being able to block it are very different things.

Often married couples come jointly, most of the time, but not always sharing the same exam room. Aspects of their relationship come right through: playful, tolerant, sometimes flat-out domineering. Watching a 75-year-old man treated like a child is not comfortable. ("Just show the doctor your back, will you?") At times, it’s the husband whose concerns about his wife’s scaly scalp or submammary keratoses are not shared by the spouse who actually has them.

In general, to be a long-married male is to be treated with well-meant and mostly-benign condescension. ("Doctor, he never uses sunscreen when we go to the beach. Tell him to use sunscreen.") I turn to the man and say, sternly, "Use sunscreen." But I put a wink in my voice. All of us understand each other.

Sometimes little kids are accompanied by both a parent and a grandparent. Contrary to the sentimental stereotype of grandma as a sagacious, even domineering matriarch, most grandparents in my office seem docile and deferential, even – or especially – the ones from an Old Country. Back in the house where language is no barrier, they may act differently, but somehow I doubt it. This is America, where youth brings wisdom, and e-mail is so last decade.

My favorite family visits are those of people married a very long time. Two months ago, I had on the same day not one but two couples, psychologically intact and living together, each pair married an astonishing 67 years.

I pointed to my student and said to one of the elderly women, who seemed especially sharp, "My young friend here is about to get married. Can you share with her any secrets of marital longevity?"

Without missing a beat, she said, "Deafness! He says, ‘Why?’ and I say ‘When?’ He says ‘What?’ and I say ‘Later.’ So we never argue."

I looked at her husband, who was smiling brightly. I don’t think he heard her.

A dermatologist’s office may not be the ideal site for family therapy, but it’s often a good place to see how close relatives interact, and even to influence their relationships a little. Many family combinations come into our offices: parents and children, husbands and wives, now and then even three generations in the same room.

Most kids and even teens don’t talk much. Asked why they’ve come, they shrug and look sideways, as if to say, "This wasn’t my idea – ask her." Once in a while, though, the child opens his or her mouth and speaks forcefully while Mom or Dad look on, probably an attorney-in-embryo or politician-in-training. Either way, the old folks probably have a tiger by the tail.

Most of the time, however, the parent does the talking while the child chafes in silence. What’s at stake is what is always in play between parents and children: control and autonomy. Mom is concerned; Junior rolls his eyes, wishing only to be left alone. Counseling in this context often calls for splitting the difference a little: letting the kid know he can eat pizza (Flash of triumph – "I told you, Ma!"), while encouraging the healthy diet that Mom feels is her probably futile but inescapable obligation to encourage. After exonerating soda and pizza, I often turn to the adolescent patient and add, "And always do your homework and listen to your mother." Mom always smiles. Sometimes the kid does, too.

Higher stakes call for greater finesse. One example is the adolescent with severe, cystic, scarring acne, whose parent has heard bad things about isotretinoin and just can’t come to terms with letting the child take it. Coming on strong is neither effective nor necessary. Delicately handled, most such tales have happy endings for both generations.

Sometimes when you meet a family you sense a particularly unhealthy dynamic. I think of the 5-year-old whose mother criticized her every time she moved. The little girl bit her lip and looked down, as her mother pronounced, "Doctor, she has to learn to behave properly." Seeing unhappiness develop before your eyes and being able to block it are very different things.

Often married couples come jointly, most of the time, but not always sharing the same exam room. Aspects of their relationship come right through: playful, tolerant, sometimes flat-out domineering. Watching a 75-year-old man treated like a child is not comfortable. ("Just show the doctor your back, will you?") At times, it’s the husband whose concerns about his wife’s scaly scalp or submammary keratoses are not shared by the spouse who actually has them.

In general, to be a long-married male is to be treated with well-meant and mostly-benign condescension. ("Doctor, he never uses sunscreen when we go to the beach. Tell him to use sunscreen.") I turn to the man and say, sternly, "Use sunscreen." But I put a wink in my voice. All of us understand each other.

Sometimes little kids are accompanied by both a parent and a grandparent. Contrary to the sentimental stereotype of grandma as a sagacious, even domineering matriarch, most grandparents in my office seem docile and deferential, even – or especially – the ones from an Old Country. Back in the house where language is no barrier, they may act differently, but somehow I doubt it. This is America, where youth brings wisdom, and e-mail is so last decade.

My favorite family visits are those of people married a very long time. Two months ago, I had on the same day not one but two couples, psychologically intact and living together, each pair married an astonishing 67 years.

I pointed to my student and said to one of the elderly women, who seemed especially sharp, "My young friend here is about to get married. Can you share with her any secrets of marital longevity?"

Without missing a beat, she said, "Deafness! He says, ‘Why?’ and I say ‘When?’ He says ‘What?’ and I say ‘Later.’ So we never argue."

I looked at her husband, who was smiling brightly. I don’t think he heard her.

Although this space is usually devoted to observations about patients and practice, this month’s column will describe an entirely new syndrome. Studying this condition may help broaden the horizons of neuroscience and deepen our understanding of the complex ways of the human brain.

Neurology recognizes many cognitive deficits, from the global (dysphasia – difficulty communicating) to the more limited (dysnomia – the inability to remember names and dyscalculia – problems counting.) I wish to describe a hitherto-unreported focal cognitive deficit, the selective inability to follow the procedures of the federal online registration program for isotretinoin, known as iPledge. I propose calling this condition DysiPledgeia.

Those who suffer from this disorder are for the most part young and generally healthy, alert and oriented, and unhampered by any linguistic or cultural barriers. When the patient is an adolescent living at home, the syndrome may be shared with parents (DysiPledgeia à deux, à trois, or, if grandparents are involved, DysiPledgeia avec toute la famille).

Of epidemiologic interest are two other observations: When iPledge requires pregnancy test reporting, most cases of DysiPledgeia are women. Another intriguing point is that nearly all cases also have severe acne.

Under the iPledge program, a registered female patient of childbearing age is required to:

• Have a negative pregnancy test, which her doctor enters into the system.

• Answer questions to demonstrate comprehension.

• Pick up isotretinoin within 7 days, bringing her 10-digit iPledge number to the pharmacy.

Some people have trouble at first following all three steps. There is debate over whether these patients have no disease, or whether they have a transient, abortive form of DysiPledgeia.

In the full-blown syndrome, patients who are otherwise cognitively intact cannot master the routine, and do not respond to educational efforts. They account for the preponderance of iPledge-related calls, which may be frightened ("I’m running out of pills!"), confused ("I don’t understand; the pharmacy won’t give them to me!"), or belligerent ("Your office didn’t do what it was supposed to!"). These calls are repeated at least monthly, and at times more often.

Explanatory responses from the medical staff are usually met with perplexity, remorse, blank incomprehension, or a combination of all three.

• Perplexity. "I waited 10 days to fill the prescription. Wasn’t somebody supposed to call me to go fill it?"

• Remorse. "I know I was supposed to get that pregnancy test!"

• Incomprehension. "Questions? What questions?"

• All three. "I gave them my number! Wait, you did say to use the one I got from the dermatologist in Texas 3 years ago, when he registered me but my insurance wouldn’t cover the medicine. What was that number again?"

Sometimes the calls can be alarming. "Wait! Which two contraceptive methods was I supposed to put down?"

The etiology and pathogenesis of DysiPledgeia are under investigation. Studies are being planned and will use imaging and neuropsychiatric testing to uncover anatomical and neurophysiologic deficits.

The intriguing correlation between DysiPledgeia and severe acne has not yet been clarified. A working hypothesis is that DysiPledgeia may be linked to a deficiency in the WBZ-1030 interleukin pathway, mediated through dystopic upregulation of mRNA caused by somatic mutations on the short arm of chromosome 14. It seems likely that deeper study of the acne-DysiPledgeia connection will help science better grasp the links between the nervous and integumentary systems. This in turn may provide insight into why dermatologists are so often handsome, charming, and highly intelligent.

Treatment for DysiPledgeia is not currently available, though fortunately this condition tends to be self-limited, rarely lasting more than 6 months. Treatment for the physician who takes care of many patients with DysiPledgeia is largely supportive: mild sedatives, long vacations, and contact sports have all been tried, with varying success.

Advances in understanding and treating this puzzling disorder, if any, will be covered in future columns. In the meantime, applications are in place to funding sources, as well as to the relevant committees overseeing ICD-9, 10, and 11. Readers with access to used CT-scanners or unemployed neuroscientists are urged to contact the editor.

Although this space is usually devoted to observations about patients and practice, this month’s column will describe an entirely new syndrome. Studying this condition may help broaden the horizons of neuroscience and deepen our understanding of the complex ways of the human brain.

Neurology recognizes many cognitive deficits, from the global (dysphasia – difficulty communicating) to the more limited (dysnomia – the inability to remember names and dyscalculia – problems counting.) I wish to describe a hitherto-unreported focal cognitive deficit, the selective inability to follow the procedures of the federal online registration program for isotretinoin, known as iPledge. I propose calling this condition DysiPledgeia.

Those who suffer from this disorder are for the most part young and generally healthy, alert and oriented, and unhampered by any linguistic or cultural barriers. When the patient is an adolescent living at home, the syndrome may be shared with parents (DysiPledgeia à deux, à trois, or, if grandparents are involved, DysiPledgeia avec toute la famille).

Of epidemiologic interest are two other observations: When iPledge requires pregnancy test reporting, most cases of DysiPledgeia are women. Another intriguing point is that nearly all cases also have severe acne.

Under the iPledge program, a registered female patient of childbearing age is required to:

• Have a negative pregnancy test, which her doctor enters into the system.

• Answer questions to demonstrate comprehension.

• Pick up isotretinoin within 7 days, bringing her 10-digit iPledge number to the pharmacy.

Some people have trouble at first following all three steps. There is debate over whether these patients have no disease, or whether they have a transient, abortive form of DysiPledgeia.

In the full-blown syndrome, patients who are otherwise cognitively intact cannot master the routine, and do not respond to educational efforts. They account for the preponderance of iPledge-related calls, which may be frightened ("I’m running out of pills!"), confused ("I don’t understand; the pharmacy won’t give them to me!"), or belligerent ("Your office didn’t do what it was supposed to!"). These calls are repeated at least monthly, and at times more often.

Explanatory responses from the medical staff are usually met with perplexity, remorse, blank incomprehension, or a combination of all three.

• Perplexity. "I waited 10 days to fill the prescription. Wasn’t somebody supposed to call me to go fill it?"

• Remorse. "I know I was supposed to get that pregnancy test!"

• Incomprehension. "Questions? What questions?"

• All three. "I gave them my number! Wait, you did say to use the one I got from the dermatologist in Texas 3 years ago, when he registered me but my insurance wouldn’t cover the medicine. What was that number again?"

Sometimes the calls can be alarming. "Wait! Which two contraceptive methods was I supposed to put down?"

The etiology and pathogenesis of DysiPledgeia are under investigation. Studies are being planned and will use imaging and neuropsychiatric testing to uncover anatomical and neurophysiologic deficits.

The intriguing correlation between DysiPledgeia and severe acne has not yet been clarified. A working hypothesis is that DysiPledgeia may be linked to a deficiency in the WBZ-1030 interleukin pathway, mediated through dystopic upregulation of mRNA caused by somatic mutations on the short arm of chromosome 14. It seems likely that deeper study of the acne-DysiPledgeia connection will help science better grasp the links between the nervous and integumentary systems. This in turn may provide insight into why dermatologists are so often handsome, charming, and highly intelligent.

Treatment for DysiPledgeia is not currently available, though fortunately this condition tends to be self-limited, rarely lasting more than 6 months. Treatment for the physician who takes care of many patients with DysiPledgeia is largely supportive: mild sedatives, long vacations, and contact sports have all been tried, with varying success.

Advances in understanding and treating this puzzling disorder, if any, will be covered in future columns. In the meantime, applications are in place to funding sources, as well as to the relevant committees overseeing ICD-9, 10, and 11. Readers with access to used CT-scanners or unemployed neuroscientists are urged to contact the editor.

Although this space is usually devoted to observations about patients and practice, this month’s column will describe an entirely new syndrome. Studying this condition may help broaden the horizons of neuroscience and deepen our understanding of the complex ways of the human brain.

Neurology recognizes many cognitive deficits, from the global (dysphasia – difficulty communicating) to the more limited (dysnomia – the inability to remember names and dyscalculia – problems counting.) I wish to describe a hitherto-unreported focal cognitive deficit, the selective inability to follow the procedures of the federal online registration program for isotretinoin, known as iPledge. I propose calling this condition DysiPledgeia.

Those who suffer from this disorder are for the most part young and generally healthy, alert and oriented, and unhampered by any linguistic or cultural barriers. When the patient is an adolescent living at home, the syndrome may be shared with parents (DysiPledgeia à deux, à trois, or, if grandparents are involved, DysiPledgeia avec toute la famille).

Of epidemiologic interest are two other observations: When iPledge requires pregnancy test reporting, most cases of DysiPledgeia are women. Another intriguing point is that nearly all cases also have severe acne.

Under the iPledge program, a registered female patient of childbearing age is required to:

• Have a negative pregnancy test, which her doctor enters into the system.

• Answer questions to demonstrate comprehension.

• Pick up isotretinoin within 7 days, bringing her 10-digit iPledge number to the pharmacy.

Some people have trouble at first following all three steps. There is debate over whether these patients have no disease, or whether they have a transient, abortive form of DysiPledgeia.

In the full-blown syndrome, patients who are otherwise cognitively intact cannot master the routine, and do not respond to educational efforts. They account for the preponderance of iPledge-related calls, which may be frightened ("I’m running out of pills!"), confused ("I don’t understand; the pharmacy won’t give them to me!"), or belligerent ("Your office didn’t do what it was supposed to!"). These calls are repeated at least monthly, and at times more often.

Explanatory responses from the medical staff are usually met with perplexity, remorse, blank incomprehension, or a combination of all three.

• Perplexity. "I waited 10 days to fill the prescription. Wasn’t somebody supposed to call me to go fill it?"

• Remorse. "I know I was supposed to get that pregnancy test!"

• Incomprehension. "Questions? What questions?"

• All three. "I gave them my number! Wait, you did say to use the one I got from the dermatologist in Texas 3 years ago, when he registered me but my insurance wouldn’t cover the medicine. What was that number again?"

Sometimes the calls can be alarming. "Wait! Which two contraceptive methods was I supposed to put down?"

The etiology and pathogenesis of DysiPledgeia are under investigation. Studies are being planned and will use imaging and neuropsychiatric testing to uncover anatomical and neurophysiologic deficits.

The intriguing correlation between DysiPledgeia and severe acne has not yet been clarified. A working hypothesis is that DysiPledgeia may be linked to a deficiency in the WBZ-1030 interleukin pathway, mediated through dystopic upregulation of mRNA caused by somatic mutations on the short arm of chromosome 14. It seems likely that deeper study of the acne-DysiPledgeia connection will help science better grasp the links between the nervous and integumentary systems. This in turn may provide insight into why dermatologists are so often handsome, charming, and highly intelligent.

Treatment for DysiPledgeia is not currently available, though fortunately this condition tends to be self-limited, rarely lasting more than 6 months. Treatment for the physician who takes care of many patients with DysiPledgeia is largely supportive: mild sedatives, long vacations, and contact sports have all been tried, with varying success.

Advances in understanding and treating this puzzling disorder, if any, will be covered in future columns. In the meantime, applications are in place to funding sources, as well as to the relevant committees overseeing ICD-9, 10, and 11. Readers with access to used CT-scanners or unemployed neuroscientists are urged to contact the editor.

It had been a long day. Only three messages needed tending to, which was a relief. Okay, I thought, let's take care of these and go home. "Hello, Mrs. Wiener, this is Dr. Rockoff calling you back."

"Good evening, Doctor. My son is getting new spots. Can I use the same cream that worked on his old spots?"

"Yes."

"Thank you. Should I use them only on the new spots or also on the old spots that went away?"

"If they went away, you don't have to treat them."

"Sometimes I get a red spot on my hand that turns white when I scratch it."

"Maybe that's because you scratch it."

"The cream you gave me worked. Can I use it again?"

"Yes."

"Last time you told me to use the cream twice a day. How many times a day should I use it now?"

"Twice a day."

"For how long?"

"2-3 days."

"And then I stop?"

"Yes, then you stop."

"That's the same thing you told me about my son."

"Yes, I am telling you the same thing about you. Will there be anything else?"

"No, I think that's it for now."

One down. Maybe the next will be quicker. It's ringing. Great, not home! "Mr. Snitzel, this is Dr. Rockoff returning your call. It's 7:00 p.m. Tuesday. Please call my office tomorrow." That's two.

"Yes, Zelda? Mr. Snitzel on line 6, he said he just missed your call? Okay, please put him through. Yes, Mr. Snitzel?"

"You just called."

"Yes, I did just call."

"My cell doesn't work in the house. You treated my wart last summer, and I have another one. How much would it cost to treat that with no insurance?"

"The fee is $100."

"Okay. Also, you treated me with two pills for a fungus. How much would they cost if I have no insurance?"

"Not sure. Would you like to cost it out before I call in the prescription?"

"Could you call it in anyway? I use PVC."

"Which PVC?"

"It's in Boston."

"What street?"

"I think Center Street. Or maybe the one on Oak. …No, Main Street."

"I'll look it up online. There's a PVC at 218 Main Street, one at 346 Main, and one at 704 Main."

"Please call the one at 704, and I'll decide if I want to buy it."

"Yes. Will there be anything else?"

"No, that's all for now. Thanks for calling."

Finally, the last message. Maybe he won't be home. "Oh, hello, Mr. Bluster. You recall the basal cell skin cancer you had on your shoulder last year? This time the biopsy showed another basal cell on your cheek. It's not serious, but it needs to be removed."

"Yes, Doctor. Before I do, I wanted to discuss this."

"Sure, what did you want to discuss?"

"I wanted to know when the first basal cell cancer on my shoulder was discovered."

"2009."

"Is there a way to know if the recent basal cell cancer on my face was completely removed?"

"It wasn't completely removed. I did a biopsy test to find out what it is. Now it needs to be removed."

"Since I have had two of these basal cell cancer cells, does this make me more likely to get them again?"

"Maybe a bit, but we'll keep a close eye on you."

"Does my risk for melanoma or other cancers go up because of these two cases?"

"Not really. We'll keep a close eye on you."

"What can I do to prevent these from occurring in the future?"

"Take care in the sun and come for regular checks."

"Is the basal cell type of cancer caused by other factors other than just the sun, like diet and stress?"

"No. Will there be anything else?"

"Yes. Who should remove this?"

"A skin surgeon. I recommend Dr. Mosey at Beth Elizabeth. His number is 888-555-MOHS."

"Why can't you do it? Is it very deep?"

"No, but the results are better on the face when a skin surgeon does it. Any further questions?"

"Yes. When should I have it taken out?"

"As soon as you can arrange it. I'm heading home now. Good night."

"Good night, Doctor. If I think of any other questions, I'll call you."

"Yes, you will. Good night."

Good night, Zelda. Zelda? She must have gone home.

It had been a long day. Only three messages needed tending to, which was a relief. Okay, I thought, let's take care of these and go home. "Hello, Mrs. Wiener, this is Dr. Rockoff calling you back."

"Good evening, Doctor. My son is getting new spots. Can I use the same cream that worked on his old spots?"

"Yes."

"Thank you. Should I use them only on the new spots or also on the old spots that went away?"

"If they went away, you don't have to treat them."

"Sometimes I get a red spot on my hand that turns white when I scratch it."

"Maybe that's because you scratch it."

"The cream you gave me worked. Can I use it again?"

"Yes."

"Last time you told me to use the cream twice a day. How many times a day should I use it now?"

"Twice a day."

"For how long?"

"2-3 days."

"And then I stop?"

"Yes, then you stop."

"That's the same thing you told me about my son."

"Yes, I am telling you the same thing about you. Will there be anything else?"

"No, I think that's it for now."

One down. Maybe the next will be quicker. It's ringing. Great, not home! "Mr. Snitzel, this is Dr. Rockoff returning your call. It's 7:00 p.m. Tuesday. Please call my office tomorrow." That's two.

"Yes, Zelda? Mr. Snitzel on line 6, he said he just missed your call? Okay, please put him through. Yes, Mr. Snitzel?"

"You just called."

"Yes, I did just call."

"My cell doesn't work in the house. You treated my wart last summer, and I have another one. How much would it cost to treat that with no insurance?"

"The fee is $100."

"Okay. Also, you treated me with two pills for a fungus. How much would they cost if I have no insurance?"

"Not sure. Would you like to cost it out before I call in the prescription?"

"Could you call it in anyway? I use PVC."

"Which PVC?"

"It's in Boston."

"What street?"

"I think Center Street. Or maybe the one on Oak. …No, Main Street."

"I'll look it up online. There's a PVC at 218 Main Street, one at 346 Main, and one at 704 Main."

"Please call the one at 704, and I'll decide if I want to buy it."

"Yes. Will there be anything else?"

"No, that's all for now. Thanks for calling."

Finally, the last message. Maybe he won't be home. "Oh, hello, Mr. Bluster. You recall the basal cell skin cancer you had on your shoulder last year? This time the biopsy showed another basal cell on your cheek. It's not serious, but it needs to be removed."

"Yes, Doctor. Before I do, I wanted to discuss this."

"Sure, what did you want to discuss?"

"I wanted to know when the first basal cell cancer on my shoulder was discovered."

"2009."

"Is there a way to know if the recent basal cell cancer on my face was completely removed?"

"It wasn't completely removed. I did a biopsy test to find out what it is. Now it needs to be removed."

"Since I have had two of these basal cell cancer cells, does this make me more likely to get them again?"

"Maybe a bit, but we'll keep a close eye on you."

"Does my risk for melanoma or other cancers go up because of these two cases?"

"Not really. We'll keep a close eye on you."

"What can I do to prevent these from occurring in the future?"

"Take care in the sun and come for regular checks."

"Is the basal cell type of cancer caused by other factors other than just the sun, like diet and stress?"

"No. Will there be anything else?"

"Yes. Who should remove this?"

"A skin surgeon. I recommend Dr. Mosey at Beth Elizabeth. His number is 888-555-MOHS."

"Why can't you do it? Is it very deep?"

"No, but the results are better on the face when a skin surgeon does it. Any further questions?"

"Yes. When should I have it taken out?"

"As soon as you can arrange it. I'm heading home now. Good night."

"Good night, Doctor. If I think of any other questions, I'll call you."

"Yes, you will. Good night."

Good night, Zelda. Zelda? She must have gone home.

It had been a long day. Only three messages needed tending to, which was a relief. Okay, I thought, let's take care of these and go home. "Hello, Mrs. Wiener, this is Dr. Rockoff calling you back."

"Good evening, Doctor. My son is getting new spots. Can I use the same cream that worked on his old spots?"

"Yes."

"Thank you. Should I use them only on the new spots or also on the old spots that went away?"

"If they went away, you don't have to treat them."

"Sometimes I get a red spot on my hand that turns white when I scratch it."

"Maybe that's because you scratch it."

"The cream you gave me worked. Can I use it again?"

"Yes."

"Last time you told me to use the cream twice a day. How many times a day should I use it now?"

"Twice a day."

"For how long?"

"2-3 days."

"And then I stop?"

"Yes, then you stop."

"That's the same thing you told me about my son."

"Yes, I am telling you the same thing about you. Will there be anything else?"

"No, I think that's it for now."

One down. Maybe the next will be quicker. It's ringing. Great, not home! "Mr. Snitzel, this is Dr. Rockoff returning your call. It's 7:00 p.m. Tuesday. Please call my office tomorrow." That's two.

"Yes, Zelda? Mr. Snitzel on line 6, he said he just missed your call? Okay, please put him through. Yes, Mr. Snitzel?"

"You just called."

"Yes, I did just call."

"My cell doesn't work in the house. You treated my wart last summer, and I have another one. How much would it cost to treat that with no insurance?"

"The fee is $100."

"Okay. Also, you treated me with two pills for a fungus. How much would they cost if I have no insurance?"

"Not sure. Would you like to cost it out before I call in the prescription?"

"Could you call it in anyway? I use PVC."

"Which PVC?"

"It's in Boston."

"What street?"

"I think Center Street. Or maybe the one on Oak. …No, Main Street."

"I'll look it up online. There's a PVC at 218 Main Street, one at 346 Main, and one at 704 Main."

"Please call the one at 704, and I'll decide if I want to buy it."

"Yes. Will there be anything else?"

"No, that's all for now. Thanks for calling."

Finally, the last message. Maybe he won't be home. "Oh, hello, Mr. Bluster. You recall the basal cell skin cancer you had on your shoulder last year? This time the biopsy showed another basal cell on your cheek. It's not serious, but it needs to be removed."

"Yes, Doctor. Before I do, I wanted to discuss this."

"Sure, what did you want to discuss?"

"I wanted to know when the first basal cell cancer on my shoulder was discovered."

"2009."

"Is there a way to know if the recent basal cell cancer on my face was completely removed?"

"It wasn't completely removed. I did a biopsy test to find out what it is. Now it needs to be removed."

"Since I have had two of these basal cell cancer cells, does this make me more likely to get them again?"

"Maybe a bit, but we'll keep a close eye on you."

"Does my risk for melanoma or other cancers go up because of these two cases?"

"Not really. We'll keep a close eye on you."

"What can I do to prevent these from occurring in the future?"

"Take care in the sun and come for regular checks."

"Is the basal cell type of cancer caused by other factors other than just the sun, like diet and stress?"

"No. Will there be anything else?"

"Yes. Who should remove this?"

"A skin surgeon. I recommend Dr. Mosey at Beth Elizabeth. His number is 888-555-MOHS."

"Why can't you do it? Is it very deep?"

"No, but the results are better on the face when a skin surgeon does it. Any further questions?"

"Yes. When should I have it taken out?"

"As soon as you can arrange it. I'm heading home now. Good night."

"Good night, Doctor. If I think of any other questions, I'll call you."

"Yes, you will. Good night."

Good night, Zelda. Zelda? She must have gone home.

We physicians are encouraged to practice evidence-based medicine whenever possible. This is a good idea, even if using evidence is not always applicable or even possible. Still, many treatments that are traditional or make sense turn out to be ineffective, or at best unproven.

But what if everybody had to act based on evidence, for instance, the program administrators who increasingly run our professional lives? I offer two examples: iPledge and ICD-10 codes.

A recent editorial reviewed the 5-year history of the iPledge program for patients taking isotretinoin (J. Am. Acad. Dermatol. 2011;65:418-9). Dr. Mary E. Maloney and Dr. Stephen P. Stone noted that iPledge has eliminated some of the software glitches that made our lives miserable at first. But has it succeeded in its stated purpose: to limit pregnancies among women taking the drug? Evidence shows that it has not.

The authors cited a recent study showing that, "in a large managed care organization, pregnancies have not decreased with the iPledge system." The reasons for this are easy enough to figure. No number of negative pregnancy tests will prevent birth control pills from sometimes failing, or stop patients from forgetting to take them.

Will the administrators of the program respond to this evidence and change or eliminate iPledge? You can hold your breath, but forgive me if I don’t join you.

Or take ICD-10, the new disease classification system, scheduled to go into effect October 2013, which will expand the number of diagnoses from 18,000 to 140,000.

ICD-10 was recently lampooned in a Wall Street Journal article by Anna Wilde Mathews ("Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way," Sept. 13, 2011). Her article pointed out interesting new disease categories, such as V91.07XA, "burn due to water-skis on fire." And, W22.02XA, "walked into lamppost, initial encounter," and W22.02 XD, "walked into lamppost, subsequent encounter." There is even a third code for "walked into lamppost, sequela."

The comments left online accompanying her article offered even more hilarious ICD-10 examples, such as T63.111A, "Toxic effect of venom of Glia monster, accidental (unintentional), initial encounter," another for the second encounter, and a third for sequela, and "Toxic effect of venom of Gila monster, intentional, initial encounter," (plus second encounter and sequela).

Such stuff is beyond parody, but it points to a serious idea that pervades our technocratic society: the fetish that more information is better. Financial firms tout their original, fundamental research that generates mounds of information and helps their portfolios shrink right along with rest of the market. IBM advertises that its "smarter planet" will give doctors up-to-the-minute information from the burgeoning literature, so they can make better diagnoses.

Right. I’ll call Watson the computer to help me diagnose my next 50 patients with acne, warts, psoriasis, and eczema.

You will fault me for being too cynical. Perhaps more information can be useful, at least sometimes. But my question is: Where is the evidence?

iPledge and ICD-10 are not random disasters of nature like tornadoes and tsunamis. They are the conscious acts of human ideas. At some point in real time, these living humans met around tables in actual rooms and decided that tabulating data on Gila monster bites (first episode, second episode, accidental, and intentional) would make the world a better place. I picture this room in a hospital OCD ward, but possibly not. Wherever they worked, the people responsible decided this because it made sense to them.

As with iPledge before it, instituting ICD-10 is a nontrivial act. Much anguish will be suffered, and much time, effort, and treasure will be spent to implement it. And why all the suffering and expense? Because doing it "makes sense."

Radical mastectomy for breast cancer once also made sense. So did forequarter amputations for melanoma of the ankle. That’s why we collect evidence and, now and then, apply it.

I have no illusions that my objections will influence any policy makers to reconsider their positions. Who’s going to make them? Their conviction that more information is better is just too strong.

I actually expect to live through a few more of these bureaucratic initiatives before I am done in by some rampant Gila monster who has a bad day, gets lost, and decides to bite me. Intentionally.

We physicians are encouraged to practice evidence-based medicine whenever possible. This is a good idea, even if using evidence is not always applicable or even possible. Still, many treatments that are traditional or make sense turn out to be ineffective, or at best unproven.

But what if everybody had to act based on evidence, for instance, the program administrators who increasingly run our professional lives? I offer two examples: iPledge and ICD-10 codes.

A recent editorial reviewed the 5-year history of the iPledge program for patients taking isotretinoin (J. Am. Acad. Dermatol. 2011;65:418-9). Dr. Mary E. Maloney and Dr. Stephen P. Stone noted that iPledge has eliminated some of the software glitches that made our lives miserable at first. But has it succeeded in its stated purpose: to limit pregnancies among women taking the drug? Evidence shows that it has not.

The authors cited a recent study showing that, "in a large managed care organization, pregnancies have not decreased with the iPledge system." The reasons for this are easy enough to figure. No number of negative pregnancy tests will prevent birth control pills from sometimes failing, or stop patients from forgetting to take them.

Will the administrators of the program respond to this evidence and change or eliminate iPledge? You can hold your breath, but forgive me if I don’t join you.

Or take ICD-10, the new disease classification system, scheduled to go into effect October 2013, which will expand the number of diagnoses from 18,000 to 140,000.

ICD-10 was recently lampooned in a Wall Street Journal article by Anna Wilde Mathews ("Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way," Sept. 13, 2011). Her article pointed out interesting new disease categories, such as V91.07XA, "burn due to water-skis on fire." And, W22.02XA, "walked into lamppost, initial encounter," and W22.02 XD, "walked into lamppost, subsequent encounter." There is even a third code for "walked into lamppost, sequela."

The comments left online accompanying her article offered even more hilarious ICD-10 examples, such as T63.111A, "Toxic effect of venom of Glia monster, accidental (unintentional), initial encounter," another for the second encounter, and a third for sequela, and "Toxic effect of venom of Gila monster, intentional, initial encounter," (plus second encounter and sequela).

Such stuff is beyond parody, but it points to a serious idea that pervades our technocratic society: the fetish that more information is better. Financial firms tout their original, fundamental research that generates mounds of information and helps their portfolios shrink right along with rest of the market. IBM advertises that its "smarter planet" will give doctors up-to-the-minute information from the burgeoning literature, so they can make better diagnoses.

Right. I’ll call Watson the computer to help me diagnose my next 50 patients with acne, warts, psoriasis, and eczema.

You will fault me for being too cynical. Perhaps more information can be useful, at least sometimes. But my question is: Where is the evidence?

iPledge and ICD-10 are not random disasters of nature like tornadoes and tsunamis. They are the conscious acts of human ideas. At some point in real time, these living humans met around tables in actual rooms and decided that tabulating data on Gila monster bites (first episode, second episode, accidental, and intentional) would make the world a better place. I picture this room in a hospital OCD ward, but possibly not. Wherever they worked, the people responsible decided this because it made sense to them.

As with iPledge before it, instituting ICD-10 is a nontrivial act. Much anguish will be suffered, and much time, effort, and treasure will be spent to implement it. And why all the suffering and expense? Because doing it "makes sense."

Radical mastectomy for breast cancer once also made sense. So did forequarter amputations for melanoma of the ankle. That’s why we collect evidence and, now and then, apply it.

I have no illusions that my objections will influence any policy makers to reconsider their positions. Who’s going to make them? Their conviction that more information is better is just too strong.

I actually expect to live through a few more of these bureaucratic initiatives before I am done in by some rampant Gila monster who has a bad day, gets lost, and decides to bite me. Intentionally.

We physicians are encouraged to practice evidence-based medicine whenever possible. This is a good idea, even if using evidence is not always applicable or even possible. Still, many treatments that are traditional or make sense turn out to be ineffective, or at best unproven.

But what if everybody had to act based on evidence, for instance, the program administrators who increasingly run our professional lives? I offer two examples: iPledge and ICD-10 codes.

A recent editorial reviewed the 5-year history of the iPledge program for patients taking isotretinoin (J. Am. Acad. Dermatol. 2011;65:418-9). Dr. Mary E. Maloney and Dr. Stephen P. Stone noted that iPledge has eliminated some of the software glitches that made our lives miserable at first. But has it succeeded in its stated purpose: to limit pregnancies among women taking the drug? Evidence shows that it has not.

The authors cited a recent study showing that, "in a large managed care organization, pregnancies have not decreased with the iPledge system." The reasons for this are easy enough to figure. No number of negative pregnancy tests will prevent birth control pills from sometimes failing, or stop patients from forgetting to take them.

Will the administrators of the program respond to this evidence and change or eliminate iPledge? You can hold your breath, but forgive me if I don’t join you.

Or take ICD-10, the new disease classification system, scheduled to go into effect October 2013, which will expand the number of diagnoses from 18,000 to 140,000.

ICD-10 was recently lampooned in a Wall Street Journal article by Anna Wilde Mathews ("Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way," Sept. 13, 2011). Her article pointed out interesting new disease categories, such as V91.07XA, "burn due to water-skis on fire." And, W22.02XA, "walked into lamppost, initial encounter," and W22.02 XD, "walked into lamppost, subsequent encounter." There is even a third code for "walked into lamppost, sequela."

The comments left online accompanying her article offered even more hilarious ICD-10 examples, such as T63.111A, "Toxic effect of venom of Glia monster, accidental (unintentional), initial encounter," another for the second encounter, and a third for sequela, and "Toxic effect of venom of Gila monster, intentional, initial encounter," (plus second encounter and sequela).

Such stuff is beyond parody, but it points to a serious idea that pervades our technocratic society: the fetish that more information is better. Financial firms tout their original, fundamental research that generates mounds of information and helps their portfolios shrink right along with rest of the market. IBM advertises that its "smarter planet" will give doctors up-to-the-minute information from the burgeoning literature, so they can make better diagnoses.

Right. I’ll call Watson the computer to help me diagnose my next 50 patients with acne, warts, psoriasis, and eczema.

You will fault me for being too cynical. Perhaps more information can be useful, at least sometimes. But my question is: Where is the evidence?

iPledge and ICD-10 are not random disasters of nature like tornadoes and tsunamis. They are the conscious acts of human ideas. At some point in real time, these living humans met around tables in actual rooms and decided that tabulating data on Gila monster bites (first episode, second episode, accidental, and intentional) would make the world a better place. I picture this room in a hospital OCD ward, but possibly not. Wherever they worked, the people responsible decided this because it made sense to them.

As with iPledge before it, instituting ICD-10 is a nontrivial act. Much anguish will be suffered, and much time, effort, and treasure will be spent to implement it. And why all the suffering and expense? Because doing it "makes sense."

Radical mastectomy for breast cancer once also made sense. So did forequarter amputations for melanoma of the ankle. That’s why we collect evidence and, now and then, apply it.

I have no illusions that my objections will influence any policy makers to reconsider their positions. Who’s going to make them? Their conviction that more information is better is just too strong.

I actually expect to live through a few more of these bureaucratic initiatives before I am done in by some rampant Gila monster who has a bad day, gets lost, and decides to bite me. Intentionally.

Barbadian lilt sounds odd coming from the mouth of a pale white woman. Martha’s Caribbean childhood has left her with not just an exotic accent but an ongoing series of nonmelanoma skin cancers.

Unscheduled, she sat on my exam table last month. The slash across her nose and right cheek made her look like a dueling-society initiate.

Martha sounded as troubled as she looked. "Dr. Martini has done the Mohs surgery on me before," she said, "but this time, I’m not sure things were handled in the best way."

"What happened?"

"I got to his office at 8:30 in the morning. At 5:30, he had finished the fourth pass and said he still found more tumor, not deeper but at the sides. I took one look at the wound in my face and told him he had to get hold of a plastic surgeon. Fortunately, Dr. Seth was still at the hospital and agreed to stay around. Dr. Martini finished a fifth pass, and Dr. Seth sewed me up before I finally went home."

After a pause, Martha continued. "Look," she said, "this is not your fault. But the basal cell was just a pinpoint, and by the time Dr. Martini was done, there was a huge, gaping hole. I just don’t have confidence that this was done right."

I considered: how to be reassuring without sounding defensive, like just another doctor circling the wagons to protect a colleague. "As you know, Martha," I said, "the point of Mohs surgery is to make sure the whole tumor is removed. They make as many passes as needed, but there’s no way to know in advance how many of them it will take or how big the wound will be."

She seemed a bit mollified, so I went on.

"I’ve sent many patients to Dr. Martini," I said, "including you a couple of times. I really think he knows his business. This tumor just turned out to be bigger than anyone could have guessed. If anything, it shows that it’s a good thing you went for the Mohs, instead of a conventional excision that could have missed all the basal cells hiding under there."

"Well, if you think so," she said, wavering. She showed me another lesion on her shin. "Then you probably would suggest he also remove this squamous cell he biopsied on my leg." I agreed that she ought to proceed.

Having addressed Martha’s concerns, I thought about all the reasons she would not be one to question the propriety of her treatment. First, Martha is not a cranky troublemaker; she has always been calm and reasoned and gracefully stoic in the face of one biopsy and surgery after another. Second, she is educated and sophisticated. She knows all about Mohs surgery and its rationale, having undergone it several times. In fact, she has had it done a few times by Dr. Martini. In a rational world, every risk manager would agree that Martha of all people would have no reason for unreasonable dissatisfaction or anger.

But when an outcome is much worse than the patient expects, correctly or not, and when she feels the visceral terror brought by seeing her face hewn open, all these rational considerations go flying out the window. Fortunately for everybody involved – including Martha – she decided to air her concerns to someone in a position to defuse them, a person who knows both patient and surgeon. It’s easy to imagine any number of alternate scenarios. She might have taken her misgivings elsewhere and gotten confusing and conflicting advice that left her frustrated, mystified, and no better off.

This story has no special moral, other than the obvious ones: Keep lines of communication open when possible and be ready to deal with anger and fear when things turn out badly, or worse than what patients decide to expect.

It’s not really fair. But then neither is illness.

Barbadian lilt sounds odd coming from the mouth of a pale white woman. Martha’s Caribbean childhood has left her with not just an exotic accent but an ongoing series of nonmelanoma skin cancers.

Unscheduled, she sat on my exam table last month. The slash across her nose and right cheek made her look like a dueling-society initiate.

Martha sounded as troubled as she looked. "Dr. Martini has done the Mohs surgery on me before," she said, "but this time, I’m not sure things were handled in the best way."

"What happened?"

"I got to his office at 8:30 in the morning. At 5:30, he had finished the fourth pass and said he still found more tumor, not deeper but at the sides. I took one look at the wound in my face and told him he had to get hold of a plastic surgeon. Fortunately, Dr. Seth was still at the hospital and agreed to stay around. Dr. Martini finished a fifth pass, and Dr. Seth sewed me up before I finally went home."

After a pause, Martha continued. "Look," she said, "this is not your fault. But the basal cell was just a pinpoint, and by the time Dr. Martini was done, there was a huge, gaping hole. I just don’t have confidence that this was done right."

I considered: how to be reassuring without sounding defensive, like just another doctor circling the wagons to protect a colleague. "As you know, Martha," I said, "the point of Mohs surgery is to make sure the whole tumor is removed. They make as many passes as needed, but there’s no way to know in advance how many of them it will take or how big the wound will be."

She seemed a bit mollified, so I went on.

"I’ve sent many patients to Dr. Martini," I said, "including you a couple of times. I really think he knows his business. This tumor just turned out to be bigger than anyone could have guessed. If anything, it shows that it’s a good thing you went for the Mohs, instead of a conventional excision that could have missed all the basal cells hiding under there."

"Well, if you think so," she said, wavering. She showed me another lesion on her shin. "Then you probably would suggest he also remove this squamous cell he biopsied on my leg." I agreed that she ought to proceed.

Having addressed Martha’s concerns, I thought about all the reasons she would not be one to question the propriety of her treatment. First, Martha is not a cranky troublemaker; she has always been calm and reasoned and gracefully stoic in the face of one biopsy and surgery after another. Second, she is educated and sophisticated. She knows all about Mohs surgery and its rationale, having undergone it several times. In fact, she has had it done a few times by Dr. Martini. In a rational world, every risk manager would agree that Martha of all people would have no reason for unreasonable dissatisfaction or anger.

But when an outcome is much worse than the patient expects, correctly or not, and when she feels the visceral terror brought by seeing her face hewn open, all these rational considerations go flying out the window. Fortunately for everybody involved – including Martha – she decided to air her concerns to someone in a position to defuse them, a person who knows both patient and surgeon. It’s easy to imagine any number of alternate scenarios. She might have taken her misgivings elsewhere and gotten confusing and conflicting advice that left her frustrated, mystified, and no better off.

This story has no special moral, other than the obvious ones: Keep lines of communication open when possible and be ready to deal with anger and fear when things turn out badly, or worse than what patients decide to expect.

It’s not really fair. But then neither is illness.

Barbadian lilt sounds odd coming from the mouth of a pale white woman. Martha’s Caribbean childhood has left her with not just an exotic accent but an ongoing series of nonmelanoma skin cancers.

Unscheduled, she sat on my exam table last month. The slash across her nose and right cheek made her look like a dueling-society initiate.

Martha sounded as troubled as she looked. "Dr. Martini has done the Mohs surgery on me before," she said, "but this time, I’m not sure things were handled in the best way."

"What happened?"

"I got to his office at 8:30 in the morning. At 5:30, he had finished the fourth pass and said he still found more tumor, not deeper but at the sides. I took one look at the wound in my face and told him he had to get hold of a plastic surgeon. Fortunately, Dr. Seth was still at the hospital and agreed to stay around. Dr. Martini finished a fifth pass, and Dr. Seth sewed me up before I finally went home."

After a pause, Martha continued. "Look," she said, "this is not your fault. But the basal cell was just a pinpoint, and by the time Dr. Martini was done, there was a huge, gaping hole. I just don’t have confidence that this was done right."

I considered: how to be reassuring without sounding defensive, like just another doctor circling the wagons to protect a colleague. "As you know, Martha," I said, "the point of Mohs surgery is to make sure the whole tumor is removed. They make as many passes as needed, but there’s no way to know in advance how many of them it will take or how big the wound will be."

She seemed a bit mollified, so I went on.

"I’ve sent many patients to Dr. Martini," I said, "including you a couple of times. I really think he knows his business. This tumor just turned out to be bigger than anyone could have guessed. If anything, it shows that it’s a good thing you went for the Mohs, instead of a conventional excision that could have missed all the basal cells hiding under there."

"Well, if you think so," she said, wavering. She showed me another lesion on her shin. "Then you probably would suggest he also remove this squamous cell he biopsied on my leg." I agreed that she ought to proceed.

Having addressed Martha’s concerns, I thought about all the reasons she would not be one to question the propriety of her treatment. First, Martha is not a cranky troublemaker; she has always been calm and reasoned and gracefully stoic in the face of one biopsy and surgery after another. Second, she is educated and sophisticated. She knows all about Mohs surgery and its rationale, having undergone it several times. In fact, she has had it done a few times by Dr. Martini. In a rational world, every risk manager would agree that Martha of all people would have no reason for unreasonable dissatisfaction or anger.

But when an outcome is much worse than the patient expects, correctly or not, and when she feels the visceral terror brought by seeing her face hewn open, all these rational considerations go flying out the window. Fortunately for everybody involved – including Martha – she decided to air her concerns to someone in a position to defuse them, a person who knows both patient and surgeon. It’s easy to imagine any number of alternate scenarios. She might have taken her misgivings elsewhere and gotten confusing and conflicting advice that left her frustrated, mystified, and no better off.

This story has no special moral, other than the obvious ones: Keep lines of communication open when possible and be ready to deal with anger and fear when things turn out badly, or worse than what patients decide to expect.

It’s not really fair. But then neither is illness.

A soft answer turns away wrath, but a harsh word stirs up anger. (Proverbs 15:1)

Storming out of the exam room, my next waiting patient saw the nurse at her desk and shoved his wristwatch literally under her nose. "Does that say 1:15?" he demanded. Before she could figure out what the devil was going on, he answered his own question. "My watch does not say 1:15!" he proclaimed. "It says 1:30!"

She managed to shepherd him back into the exam room. "The doctor will be right with you," she said. A moment later, I was.

"Hello, I’m Dr. Rockoff," I said.

"My appointment was at 1:15," he retorted. "It is now after 1:30. Why is it that you doctors only care about your own time and not about the time of your patients?"

"I’m really sorry to have kept you waiting," I said, although I really wasn’t all that sorry.

"I have a skin cancer that has to be taken off my back," he said.

"I see that my assistant performed a biopsy," I replied.

"And she was a lot more prompt than you," he said.

"Well," I said, "I will try to improve."

"It’s the whole medical profession," he continued. "They don’t have the courtesy to care about the time of their patients; they only care about their own convenience."

"In that case," I said, "please accept my apologies on behalf of my entire profession." He seemed a bit mollified. In any case, he quieted down.

"You have a basal cell skin cancer on your back," I said. "It should just take a few moments to burn it off."

"My father had several," he said. "Now that I have one, too, maybe my brother will finally have his skin checked out. He lives in Maryland."

While I prepared lidocaine, gauze, and curettes, he began to reminisce about past medical inconveniences.

"I was at an allergist’s once," he said. "I sat there for 40 minutes. Not one patient was taken to the back. I got up and asked where the doctor was. ‘He’s been called away on an emergency,’ the secretary said. ‘Well,’ I told her, ‘were you going to tell anyone, or were you just going to let us sit here?’ Can you believe that?"

I agreed that it was hard to believe. "What sort of emergency would an allergist be called away on?" I wondered.

"That’s right," he said. "I could understand an orthopedist being called away for something urgent, but an allergist?"

"Maybe he had something going at the track," I mused, but got no response. I administered the lidocaine.

"Why does it have to hurt?" he asked. I gave no answer, having none.

"The allergist’s secretary told me to sit down or else she would call the police," he said. "I said, ‘You go right ahead and do that!’ "

"Well," I said, picking up the curette, "I think that was unconscionable."

"Thank you for seeing my point of view," he said.

"You’re welcome," I said.

A few minutes later, I was done. "You’re all set," I said. "See you back in 6 months."

"I’ll make the appointment," he said.

"When you come back, we will try very hard to be prompt," I said.

"I certainly hope you will," he said, exiting. He glared at the nurse under whose nose he had shoved his watch, then grunted and headed for the front desk.

When I saw that he’d left the office, I pulled my tongue back out of my cheek. Then the whole staff and I shared a wink, a chuckle, and a sigh of relief.

Life brings challenges to confront and battles to fight. In the office there are insurers, government agencies, landlords, partners, and others who may have to be stood up to from time to time. But some challengers are just too silly to take seriously. More and more battles don’t seem to be worth fighting as I get older. I find it better to answer softly, deflect, and move on. Promptly!

A soft answer turns away wrath, but a harsh word stirs up anger. (Proverbs 15:1)

Storming out of the exam room, my next waiting patient saw the nurse at her desk and shoved his wristwatch literally under her nose. "Does that say 1:15?" he demanded. Before she could figure out what the devil was going on, he answered his own question. "My watch does not say 1:15!" he proclaimed. "It says 1:30!"

She managed to shepherd him back into the exam room. "The doctor will be right with you," she said. A moment later, I was.

"Hello, I’m Dr. Rockoff," I said.

"My appointment was at 1:15," he retorted. "It is now after 1:30. Why is it that you doctors only care about your own time and not about the time of your patients?"

"I’m really sorry to have kept you waiting," I said, although I really wasn’t all that sorry.

"I have a skin cancer that has to be taken off my back," he said.

"I see that my assistant performed a biopsy," I replied.

"And she was a lot more prompt than you," he said.

"Well," I said, "I will try to improve."

"It’s the whole medical profession," he continued. "They don’t have the courtesy to care about the time of their patients; they only care about their own convenience."

"In that case," I said, "please accept my apologies on behalf of my entire profession." He seemed a bit mollified. In any case, he quieted down.

"You have a basal cell skin cancer on your back," I said. "It should just take a few moments to burn it off."

"My father had several," he said. "Now that I have one, too, maybe my brother will finally have his skin checked out. He lives in Maryland."

While I prepared lidocaine, gauze, and curettes, he began to reminisce about past medical inconveniences.

"I was at an allergist’s once," he said. "I sat there for 40 minutes. Not one patient was taken to the back. I got up and asked where the doctor was. ‘He’s been called away on an emergency,’ the secretary said. ‘Well,’ I told her, ‘were you going to tell anyone, or were you just going to let us sit here?’ Can you believe that?"

I agreed that it was hard to believe. "What sort of emergency would an allergist be called away on?" I wondered.

"That’s right," he said. "I could understand an orthopedist being called away for something urgent, but an allergist?"

"Maybe he had something going at the track," I mused, but got no response. I administered the lidocaine.

"Why does it have to hurt?" he asked. I gave no answer, having none.

"The allergist’s secretary told me to sit down or else she would call the police," he said. "I said, ‘You go right ahead and do that!’ "

"Well," I said, picking up the curette, "I think that was unconscionable."

"Thank you for seeing my point of view," he said.

"You’re welcome," I said.

A few minutes later, I was done. "You’re all set," I said. "See you back in 6 months."

"I’ll make the appointment," he said.

"When you come back, we will try very hard to be prompt," I said.

"I certainly hope you will," he said, exiting. He glared at the nurse under whose nose he had shoved his watch, then grunted and headed for the front desk.

When I saw that he’d left the office, I pulled my tongue back out of my cheek. Then the whole staff and I shared a wink, a chuckle, and a sigh of relief.

Life brings challenges to confront and battles to fight. In the office there are insurers, government agencies, landlords, partners, and others who may have to be stood up to from time to time. But some challengers are just too silly to take seriously. More and more battles don’t seem to be worth fighting as I get older. I find it better to answer softly, deflect, and move on. Promptly!

A soft answer turns away wrath, but a harsh word stirs up anger. (Proverbs 15:1)

Storming out of the exam room, my next waiting patient saw the nurse at her desk and shoved his wristwatch literally under her nose. "Does that say 1:15?" he demanded. Before she could figure out what the devil was going on, he answered his own question. "My watch does not say 1:15!" he proclaimed. "It says 1:30!"

She managed to shepherd him back into the exam room. "The doctor will be right with you," she said. A moment later, I was.

"Hello, I’m Dr. Rockoff," I said.

"My appointment was at 1:15," he retorted. "It is now after 1:30. Why is it that you doctors only care about your own time and not about the time of your patients?"

"I’m really sorry to have kept you waiting," I said, although I really wasn’t all that sorry.

"I have a skin cancer that has to be taken off my back," he said.

"I see that my assistant performed a biopsy," I replied.

"And she was a lot more prompt than you," he said.

"Well," I said, "I will try to improve."

"It’s the whole medical profession," he continued. "They don’t have the courtesy to care about the time of their patients; they only care about their own convenience."

"In that case," I said, "please accept my apologies on behalf of my entire profession." He seemed a bit mollified. In any case, he quieted down.

"You have a basal cell skin cancer on your back," I said. "It should just take a few moments to burn it off."

"My father had several," he said. "Now that I have one, too, maybe my brother will finally have his skin checked out. He lives in Maryland."

While I prepared lidocaine, gauze, and curettes, he began to reminisce about past medical inconveniences.

"I was at an allergist’s once," he said. "I sat there for 40 minutes. Not one patient was taken to the back. I got up and asked where the doctor was. ‘He’s been called away on an emergency,’ the secretary said. ‘Well,’ I told her, ‘were you going to tell anyone, or were you just going to let us sit here?’ Can you believe that?"

I agreed that it was hard to believe. "What sort of emergency would an allergist be called away on?" I wondered.

"That’s right," he said. "I could understand an orthopedist being called away for something urgent, but an allergist?"

"Maybe he had something going at the track," I mused, but got no response. I administered the lidocaine.

"Why does it have to hurt?" he asked. I gave no answer, having none.

"The allergist’s secretary told me to sit down or else she would call the police," he said. "I said, ‘You go right ahead and do that!’ "

"Well," I said, picking up the curette, "I think that was unconscionable."

"Thank you for seeing my point of view," he said.

"You’re welcome," I said.

A few minutes later, I was done. "You’re all set," I said. "See you back in 6 months."

"I’ll make the appointment," he said.

"When you come back, we will try very hard to be prompt," I said.

"I certainly hope you will," he said, exiting. He glared at the nurse under whose nose he had shoved his watch, then grunted and headed for the front desk.

When I saw that he’d left the office, I pulled my tongue back out of my cheek. Then the whole staff and I shared a wink, a chuckle, and a sigh of relief.

Life brings challenges to confront and battles to fight. In the office there are insurers, government agencies, landlords, partners, and others who may have to be stood up to from time to time. But some challengers are just too silly to take seriously. More and more battles don’t seem to be worth fighting as I get older. I find it better to answer softly, deflect, and move on. Promptly!

You’ll just have to take my word for the fact that this story happened exactly this way. Only the names have been changed to protect the incompetent.

“Denny Dugan called, Doctor. You told him he might have trouble getting the medicine you prescribed, and that seems to be happening.”

“Hello, Mr. Dugan. Your pharmacy says they don’t have the Xolotl-PC? Can’t they order it?”

“It’s the mail-order pharmacy, Doctor, Meddle Co. They say they need to speak with you.”

“Why not try your local pharmacy?”

“I use mail order, Doctor. I’m very cost conscious.”

[Yes, I thought, you’re very cost conscious with my time.]

“Rosebud, could you please call Meddle Co.? Here’s the patient’s name, date of birth, and ID number. You have my license, DEA, and UPIN. Please buzz me when you get to the right person.”

“Hi, Doctor, it’s Rosebud. I went through four other people before I got to this one. I gave every one of them the patient’s numbers and your numbers. The second person told me that this is a covered medicine, no prior authorization needed, but I told him that someone said they needed to talk to you about it, so they kept on transferring me. Anyhow, the pharmacist is on line 6.”

“Hello, this is Dr. Rockoff. What did you need to talk to me about?”

“Good morning, Doctor. You wrote for Xolotl-PC for Mr. Dugan, manufactured by Peeples & Cootie.”

“That’s correct. Do you have it?”

“Did you want the Xolotl-PC solution?”

“I think that’s how it comes.”

“There is also a gel.”

“I didn’t know that.”

“But the gel has been discontinued.”

“I see. So you wanted to speak with me to ask whether I want the solution, or the gel that’s been discontinued?”

“Yes.”

“I think I’ll go with the solution.”

“Yes, Doctor, just wanted to check if that’s the one you want.”

“Was there anything else?”

“Yes. You wrote that Xolotl-PC is manufactured by Peeples & Cootie.”

“I just put that down in case the drug was unfamiliar and needed to be ordered.”

“So you want that manufacturer?”

“If it’s available as generic, then I don’t care whom it’s manufactured by. Does anybody else make it?”

“No.”

“Then what do you want to know?”

“We’re just checking to see if you want the product manufactured by Peeples & Cootie.”

“But nobody else makes it.”

“Yes. But we just wanted to be sure that’s the one you wanted.”

“So you told the patient that you have to speak to me because you needed to find out whether I want the solution or the gel that’s been discontinued and if I want the drug that is manufactured by its only manufacturer?”

“Yes, Doctor. We just like to check to be sure that the medication we dispense is the one you want.”

“Well, now I guess you’re sure.”

“Yes, Doctor.”

“OK. I guess I’ll go back to seeing patients now. Have a nice day.”

“You, too, Doctor.”

“Mr. Dugan, I spoke with Meddle Co., and it’s all set.”

“Thanks a million, Doc. I really appreciate it! You know how important it is these days to be cost conscious.”

You’ll just have to take my word for the fact that this story happened exactly this way. Only the names have been changed to protect the incompetent.

“Denny Dugan called, Doctor. You told him he might have trouble getting the medicine you prescribed, and that seems to be happening.”

“Hello, Mr. Dugan. Your pharmacy says they don’t have the Xolotl-PC? Can’t they order it?”

“It’s the mail-order pharmacy, Doctor, Meddle Co. They say they need to speak with you.”

“Why not try your local pharmacy?”

“I use mail order, Doctor. I’m very cost conscious.”

[Yes, I thought, you’re very cost conscious with my time.]

“Rosebud, could you please call Meddle Co.? Here’s the patient’s name, date of birth, and ID number. You have my license, DEA, and UPIN. Please buzz me when you get to the right person.”

“Hi, Doctor, it’s Rosebud. I went through four other people before I got to this one. I gave every one of them the patient’s numbers and your numbers. The second person told me that this is a covered medicine, no prior authorization needed, but I told him that someone said they needed to talk to you about it, so they kept on transferring me. Anyhow, the pharmacist is on line 6.”

“Hello, this is Dr. Rockoff. What did you need to talk to me about?”

“Good morning, Doctor. You wrote for Xolotl-PC for Mr. Dugan, manufactured by Peeples & Cootie.”

“That’s correct. Do you have it?”

“Did you want the Xolotl-PC solution?”

“I think that’s how it comes.”

“There is also a gel.”

“I didn’t know that.”

“But the gel has been discontinued.”

“I see. So you wanted to speak with me to ask whether I want the solution, or the gel that’s been discontinued?”

“Yes.”

“I think I’ll go with the solution.”

“Yes, Doctor, just wanted to check if that’s the one you want.”

“Was there anything else?”

“Yes. You wrote that Xolotl-PC is manufactured by Peeples & Cootie.”

“I just put that down in case the drug was unfamiliar and needed to be ordered.”

“So you want that manufacturer?”

“If it’s available as generic, then I don’t care whom it’s manufactured by. Does anybody else make it?”

“No.”

“Then what do you want to know?”

“We’re just checking to see if you want the product manufactured by Peeples & Cootie.”

“But nobody else makes it.”

“Yes. But we just wanted to be sure that’s the one you wanted.”

“So you told the patient that you have to speak to me because you needed to find out whether I want the solution or the gel that’s been discontinued and if I want the drug that is manufactured by its only manufacturer?”

“Yes, Doctor. We just like to check to be sure that the medication we dispense is the one you want.”

“Well, now I guess you’re sure.”

“Yes, Doctor.”

“OK. I guess I’ll go back to seeing patients now. Have a nice day.”

“You, too, Doctor.”

“Mr. Dugan, I spoke with Meddle Co., and it’s all set.”

“Thanks a million, Doc. I really appreciate it! You know how important it is these days to be cost conscious.”

You’ll just have to take my word for the fact that this story happened exactly this way. Only the names have been changed to protect the incompetent.

“Denny Dugan called, Doctor. You told him he might have trouble getting the medicine you prescribed, and that seems to be happening.”

“Hello, Mr. Dugan. Your pharmacy says they don’t have the Xolotl-PC? Can’t they order it?”

“It’s the mail-order pharmacy, Doctor, Meddle Co. They say they need to speak with you.”

“Why not try your local pharmacy?”

“I use mail order, Doctor. I’m very cost conscious.”

[Yes, I thought, you’re very cost conscious with my time.]

“Rosebud, could you please call Meddle Co.? Here’s the patient’s name, date of birth, and ID number. You have my license, DEA, and UPIN. Please buzz me when you get to the right person.”

“Hi, Doctor, it’s Rosebud. I went through four other people before I got to this one. I gave every one of them the patient’s numbers and your numbers. The second person told me that this is a covered medicine, no prior authorization needed, but I told him that someone said they needed to talk to you about it, so they kept on transferring me. Anyhow, the pharmacist is on line 6.”

“Hello, this is Dr. Rockoff. What did you need to talk to me about?”

“Good morning, Doctor. You wrote for Xolotl-PC for Mr. Dugan, manufactured by Peeples & Cootie.”

“That’s correct. Do you have it?”

“Did you want the Xolotl-PC solution?”

“I think that’s how it comes.”

“There is also a gel.”

“I didn’t know that.”

“But the gel has been discontinued.”

“I see. So you wanted to speak with me to ask whether I want the solution, or the gel that’s been discontinued?”

“Yes.”

“I think I’ll go with the solution.”

“Yes, Doctor, just wanted to check if that’s the one you want.”

“Was there anything else?”

“Yes. You wrote that Xolotl-PC is manufactured by Peeples & Cootie.”

“I just put that down in case the drug was unfamiliar and needed to be ordered.”

“So you want that manufacturer?”

“If it’s available as generic, then I don’t care whom it’s manufactured by. Does anybody else make it?”

“No.”

“Then what do you want to know?”

“We’re just checking to see if you want the product manufactured by Peeples & Cootie.”

“But nobody else makes it.”

“Yes. But we just wanted to be sure that’s the one you wanted.”

“So you told the patient that you have to speak to me because you needed to find out whether I want the solution or the gel that’s been discontinued and if I want the drug that is manufactured by its only manufacturer?”

“Yes, Doctor. We just like to check to be sure that the medication we dispense is the one you want.”

“Well, now I guess you’re sure.”

“Yes, Doctor.”

“OK. I guess I’ll go back to seeing patients now. Have a nice day.”

“You, too, Doctor.”

“Mr. Dugan, I spoke with Meddle Co., and it’s all set.”

“Thanks a million, Doc. I really appreciate it! You know how important it is these days to be cost conscious.”