Alan M. Rockoff

I'm not sure why I agreed to speak at the mall, and gratis at that. Maybe it was nostalgia for the talks to community groups, primary care doctors, and television interviewers (at small, public-access stations) that I used to give when I was starting out. Or maybe it is because I just like to talk.

When I got to the local mall at 9:45 a.m., my hopes for a good crowd rose when I saw lines of people stretching out into the lobby. That lasted until I realized they were there for the Registry of Motor Vehicles.

My talk would be next door at the buffet restaurant. Posters announced this month's installment of the Health Awareness series, “Advances in Skin Cancer.” I met Janice, a twenty-something in charge of marketing for the strip mall. She led me inside the still-closed restaurant.

“Usually, they're done vacuuming before the lectures start,” she said. “You'll be speaking from here.” She pointed to a wood busing station against the near wall. I turned to face long, neat rows of small tables, each set with salt, pepper, ketchup, and steak sauce.

“How did you get my name?” I asked Janice.

“Google,” she replied. “Would you believe we called 30 dermatologists before we found you? The others were too busy or not interested.”

That was gratifying. “Do you get the same people coming to the lectures every month?”

“Pretty much,” she said as she indicated a list of regulars. “They check off their name so we can send them announcements.”

By then people started showing up. They all seemed to know Janice and each other. “These are good seats,” said one woman to her companion, taking a table in front.

Others shuffled in. By just after 10 a.m., 15 people had signed in and sat down. All were old and wan.

One woman sported a bulky gauze dressing on her left cheek. “My dermatologist took off a skin cancer this week,” she said, heading to her table.

“What kind of cancer was it?” I asked.

“I don't know,” she said. “I forgot to ask him.”

Janice offered no introduction. She distributed my one-page handout.

As instructed, I had brought no slides or PowerPoint presentations; the restaurant walls were unsuitable for either. My handout listed a number of Web sites on which to find pictures of skin cancer, though this crowd seemed unlikely to spend much time online.

I told them about basal and squamous cell carcinoma, melanoma, UVA and UVB, sunscreens, and vitamin D. I also mentioned tanning parlors, and we shared chuckles about the foolishness of kids.

One woman rose to testify. “I know my skin cancer came from a terrible sunburn on my chest,” she said. “My skin turned blue. Then I got this small, dark spot. One doctor said to forget about it, but I went to another one, and they did a test.”

I agreed that sunburns are undesirable, but suggested that a single bad one wouldn't necessarily generate cancer.

“What strength sunscreen do you recommend?” asked one woman.

“He already answered that,” said her table mate. “You have to pay attention!” I assumed this pair shared similar interchanges every month.

And so it went. The props were different from those in the old days: Instead of screens, slide projectors, or TV cameras, I now faced rows of inverted Heinz ketchup bottles. But the rest was familiar: the same facts, advice, questions, and even my jokes and their predictable responses. Everything about those talks came flooding back, including why I'd stopped giving them.

The public can't get enough medical news. What people really want to hear about are the breakthroughs and the exciting advances. Those of us who don't live on the clinical cutting edge have more mundane fare to offer, less like what comes from the lab bench or operating suite than what emanates from the pulpit.

Like pastors, we offer sage wisdom and sensible advice to people inclined to listen to us. They nod in agreement, and not much changes.

Also, like pastors, we don't give up. The same regulars come time after time, only maybe this time they'll pay closer attention so that our words hit home and nudge them a bit in the right direction.

So maybe that's why I agreed to speak. Or maybe I just like to talk.

I'm not sure why I agreed to speak at the mall, and gratis at that. Maybe it was nostalgia for the talks to community groups, primary care doctors, and television interviewers (at small, public-access stations) that I used to give when I was starting out. Or maybe it is because I just like to talk.

When I got to the local mall at 9:45 a.m., my hopes for a good crowd rose when I saw lines of people stretching out into the lobby. That lasted until I realized they were there for the Registry of Motor Vehicles.

My talk would be next door at the buffet restaurant. Posters announced this month's installment of the Health Awareness series, “Advances in Skin Cancer.” I met Janice, a twenty-something in charge of marketing for the strip mall. She led me inside the still-closed restaurant.

“Usually, they're done vacuuming before the lectures start,” she said. “You'll be speaking from here.” She pointed to a wood busing station against the near wall. I turned to face long, neat rows of small tables, each set with salt, pepper, ketchup, and steak sauce.

“How did you get my name?” I asked Janice.

“Google,” she replied. “Would you believe we called 30 dermatologists before we found you? The others were too busy or not interested.”

That was gratifying. “Do you get the same people coming to the lectures every month?”

“Pretty much,” she said as she indicated a list of regulars. “They check off their name so we can send them announcements.”

By then people started showing up. They all seemed to know Janice and each other. “These are good seats,” said one woman to her companion, taking a table in front.

Others shuffled in. By just after 10 a.m., 15 people had signed in and sat down. All were old and wan.

One woman sported a bulky gauze dressing on her left cheek. “My dermatologist took off a skin cancer this week,” she said, heading to her table.

“What kind of cancer was it?” I asked.

“I don't know,” she said. “I forgot to ask him.”

Janice offered no introduction. She distributed my one-page handout.

As instructed, I had brought no slides or PowerPoint presentations; the restaurant walls were unsuitable for either. My handout listed a number of Web sites on which to find pictures of skin cancer, though this crowd seemed unlikely to spend much time online.

I told them about basal and squamous cell carcinoma, melanoma, UVA and UVB, sunscreens, and vitamin D. I also mentioned tanning parlors, and we shared chuckles about the foolishness of kids.

One woman rose to testify. “I know my skin cancer came from a terrible sunburn on my chest,” she said. “My skin turned blue. Then I got this small, dark spot. One doctor said to forget about it, but I went to another one, and they did a test.”

I agreed that sunburns are undesirable, but suggested that a single bad one wouldn't necessarily generate cancer.

“What strength sunscreen do you recommend?” asked one woman.

“He already answered that,” said her table mate. “You have to pay attention!” I assumed this pair shared similar interchanges every month.

And so it went. The props were different from those in the old days: Instead of screens, slide projectors, or TV cameras, I now faced rows of inverted Heinz ketchup bottles. But the rest was familiar: the same facts, advice, questions, and even my jokes and their predictable responses. Everything about those talks came flooding back, including why I'd stopped giving them.

The public can't get enough medical news. What people really want to hear about are the breakthroughs and the exciting advances. Those of us who don't live on the clinical cutting edge have more mundane fare to offer, less like what comes from the lab bench or operating suite than what emanates from the pulpit.

Like pastors, we offer sage wisdom and sensible advice to people inclined to listen to us. They nod in agreement, and not much changes.

Also, like pastors, we don't give up. The same regulars come time after time, only maybe this time they'll pay closer attention so that our words hit home and nudge them a bit in the right direction.

So maybe that's why I agreed to speak. Or maybe I just like to talk.

I'm not sure why I agreed to speak at the mall, and gratis at that. Maybe it was nostalgia for the talks to community groups, primary care doctors, and television interviewers (at small, public-access stations) that I used to give when I was starting out. Or maybe it is because I just like to talk.

When I got to the local mall at 9:45 a.m., my hopes for a good crowd rose when I saw lines of people stretching out into the lobby. That lasted until I realized they were there for the Registry of Motor Vehicles.

My talk would be next door at the buffet restaurant. Posters announced this month's installment of the Health Awareness series, “Advances in Skin Cancer.” I met Janice, a twenty-something in charge of marketing for the strip mall. She led me inside the still-closed restaurant.

“Usually, they're done vacuuming before the lectures start,” she said. “You'll be speaking from here.” She pointed to a wood busing station against the near wall. I turned to face long, neat rows of small tables, each set with salt, pepper, ketchup, and steak sauce.

“How did you get my name?” I asked Janice.

“Google,” she replied. “Would you believe we called 30 dermatologists before we found you? The others were too busy or not interested.”

That was gratifying. “Do you get the same people coming to the lectures every month?”

“Pretty much,” she said as she indicated a list of regulars. “They check off their name so we can send them announcements.”

By then people started showing up. They all seemed to know Janice and each other. “These are good seats,” said one woman to her companion, taking a table in front.

Others shuffled in. By just after 10 a.m., 15 people had signed in and sat down. All were old and wan.

One woman sported a bulky gauze dressing on her left cheek. “My dermatologist took off a skin cancer this week,” she said, heading to her table.

“What kind of cancer was it?” I asked.

“I don't know,” she said. “I forgot to ask him.”

Janice offered no introduction. She distributed my one-page handout.

As instructed, I had brought no slides or PowerPoint presentations; the restaurant walls were unsuitable for either. My handout listed a number of Web sites on which to find pictures of skin cancer, though this crowd seemed unlikely to spend much time online.

I told them about basal and squamous cell carcinoma, melanoma, UVA and UVB, sunscreens, and vitamin D. I also mentioned tanning parlors, and we shared chuckles about the foolishness of kids.

One woman rose to testify. “I know my skin cancer came from a terrible sunburn on my chest,” she said. “My skin turned blue. Then I got this small, dark spot. One doctor said to forget about it, but I went to another one, and they did a test.”

I agreed that sunburns are undesirable, but suggested that a single bad one wouldn't necessarily generate cancer.

“What strength sunscreen do you recommend?” asked one woman.

“He already answered that,” said her table mate. “You have to pay attention!” I assumed this pair shared similar interchanges every month.

And so it went. The props were different from those in the old days: Instead of screens, slide projectors, or TV cameras, I now faced rows of inverted Heinz ketchup bottles. But the rest was familiar: the same facts, advice, questions, and even my jokes and their predictable responses. Everything about those talks came flooding back, including why I'd stopped giving them.

The public can't get enough medical news. What people really want to hear about are the breakthroughs and the exciting advances. Those of us who don't live on the clinical cutting edge have more mundane fare to offer, less like what comes from the lab bench or operating suite than what emanates from the pulpit.

Like pastors, we offer sage wisdom and sensible advice to people inclined to listen to us. They nod in agreement, and not much changes.

Also, like pastors, we don't give up. The same regulars come time after time, only maybe this time they'll pay closer attention so that our words hit home and nudge them a bit in the right direction.

So maybe that's why I agreed to speak. Or maybe I just like to talk.

From a recent article in the New York Times: “The Cleveland Clinic has lent its name and backup services to a string of CVS drugstore clinics in northeastern Ohio. And the Mayo Clinic is in the game, operating one Express Care clinic at a supermarket in Rochester, Minn.” (“Hospitals Begin to Move Into Supermarkets,” May 11, 2009).

“How may I help you?”

“I need frozen peas, strawberry jam, and a skin cancer screen.”

“Frozen peas, aisle 6; jams and preserves, aisle 8; skin screens right here.”

“Right here? Terrific.”

“Yes. Please undress and we'll have a look.”

“In the aisle?”

“Just kidding. You can proceed to the booth next to the deli counter. Have you seen a dermatologist lately?”

“Yes. I got a screen at CostSlasher last month.”

“Then why do you need another one?”

“I just finished a tanning series to get ready for a cruise, and I'm feeling guilty and vulnerable. Do you offer other services besides skin cancer screening?”

“Sure. What else have you got?”

“I have this wart on my index finger—OUCHHHH! What was that?”

“Liquid nitrogen. What else is going on?”

“I've been breaking out.”

“Cleansers, aisle 12, and here's a prescription.”

“Thanks. Can I fill it anywhere?”

“We have an exclusive with MachDonald's Pharmacy. Is there anything else?”

“My wife gave me a list. Let's see, laundry detergent, milk, whole wheat muffins—oh, yes, she wants you to look at this mole on my scalp. HEY, CUT THAT OUT!”

“I just performed a shave biopsy. We'll mail you the results next week with the next batch of coupons. Please take this card.”

“What is it?”

“Log onto our Web site and enter this eight-digit alphanumeric code. It makes you a member of our SuperSlashShopper VIP Club, which entitles you to one emergency appointment at one of our offices for the next 6 weeks.”

“Well, I guess all I need is that skin screen.”

“Before you get undressed, would you like e-mail updates about our specials?”

“No thanks.”

“In that case, I'll tell you about them now. Refer a friend or family member and get 15% off any three products in our signature, private-label skin care line.”

“Okay. I'll see.”

“Removal of pigmented spots, half price?”

“No thanks.”

“Laser off two blood vessels, get the third one free?”

“Not interested.”

“How about a package of three photorejuvenation sessions at 20% off?”

“No, thank you. Wait. I just remembered, my wife needs help with a coleslaw recipe using low-fat mayonnaise.”

“Mayo Clinic, aisle 3. Cleveland Clinic, aisle 2. Well, thanks for coming.”

“Hold on. What about my skin screen?”

“Sorry, I forgot. Why did you want another one?”

“I'm tanned, guilty, and vulnerable.”

“Right. In that case you should see my colleague.”

“What colleague?”

“A psychiatrist. He's in fresh produce, behind the broccoli. Next!”

From a recent article in the New York Times: “The Cleveland Clinic has lent its name and backup services to a string of CVS drugstore clinics in northeastern Ohio. And the Mayo Clinic is in the game, operating one Express Care clinic at a supermarket in Rochester, Minn.” (“Hospitals Begin to Move Into Supermarkets,” May 11, 2009).

“How may I help you?”

“I need frozen peas, strawberry jam, and a skin cancer screen.”

“Frozen peas, aisle 6; jams and preserves, aisle 8; skin screens right here.”

“Right here? Terrific.”

“Yes. Please undress and we'll have a look.”

“In the aisle?”

“Just kidding. You can proceed to the booth next to the deli counter. Have you seen a dermatologist lately?”

“Yes. I got a screen at CostSlasher last month.”

“Then why do you need another one?”

“I just finished a tanning series to get ready for a cruise, and I'm feeling guilty and vulnerable. Do you offer other services besides skin cancer screening?”

“Sure. What else have you got?”

“I have this wart on my index finger—OUCHHHH! What was that?”

“Liquid nitrogen. What else is going on?”

“I've been breaking out.”

“Cleansers, aisle 12, and here's a prescription.”

“Thanks. Can I fill it anywhere?”

“We have an exclusive with MachDonald's Pharmacy. Is there anything else?”

“My wife gave me a list. Let's see, laundry detergent, milk, whole wheat muffins—oh, yes, she wants you to look at this mole on my scalp. HEY, CUT THAT OUT!”

“I just performed a shave biopsy. We'll mail you the results next week with the next batch of coupons. Please take this card.”

“What is it?”

“Log onto our Web site and enter this eight-digit alphanumeric code. It makes you a member of our SuperSlashShopper VIP Club, which entitles you to one emergency appointment at one of our offices for the next 6 weeks.”

“Well, I guess all I need is that skin screen.”

“Before you get undressed, would you like e-mail updates about our specials?”

“No thanks.”

“In that case, I'll tell you about them now. Refer a friend or family member and get 15% off any three products in our signature, private-label skin care line.”

“Okay. I'll see.”

“Removal of pigmented spots, half price?”

“No thanks.”

“Laser off two blood vessels, get the third one free?”

“Not interested.”

“How about a package of three photorejuvenation sessions at 20% off?”

“No, thank you. Wait. I just remembered, my wife needs help with a coleslaw recipe using low-fat mayonnaise.”

“Mayo Clinic, aisle 3. Cleveland Clinic, aisle 2. Well, thanks for coming.”

“Hold on. What about my skin screen?”

“Sorry, I forgot. Why did you want another one?”

“I'm tanned, guilty, and vulnerable.”

“Right. In that case you should see my colleague.”

“What colleague?”

“A psychiatrist. He's in fresh produce, behind the broccoli. Next!”

From a recent article in the New York Times: “The Cleveland Clinic has lent its name and backup services to a string of CVS drugstore clinics in northeastern Ohio. And the Mayo Clinic is in the game, operating one Express Care clinic at a supermarket in Rochester, Minn.” (“Hospitals Begin to Move Into Supermarkets,” May 11, 2009).

“How may I help you?”

“I need frozen peas, strawberry jam, and a skin cancer screen.”

“Frozen peas, aisle 6; jams and preserves, aisle 8; skin screens right here.”

“Right here? Terrific.”

“Yes. Please undress and we'll have a look.”

“In the aisle?”

“Just kidding. You can proceed to the booth next to the deli counter. Have you seen a dermatologist lately?”

“Yes. I got a screen at CostSlasher last month.”

“Then why do you need another one?”

“I just finished a tanning series to get ready for a cruise, and I'm feeling guilty and vulnerable. Do you offer other services besides skin cancer screening?”

“Sure. What else have you got?”

“I have this wart on my index finger—OUCHHHH! What was that?”

“Liquid nitrogen. What else is going on?”

“I've been breaking out.”

“Cleansers, aisle 12, and here's a prescription.”

“Thanks. Can I fill it anywhere?”

“We have an exclusive with MachDonald's Pharmacy. Is there anything else?”

“My wife gave me a list. Let's see, laundry detergent, milk, whole wheat muffins—oh, yes, she wants you to look at this mole on my scalp. HEY, CUT THAT OUT!”

“I just performed a shave biopsy. We'll mail you the results next week with the next batch of coupons. Please take this card.”

“What is it?”

“Log onto our Web site and enter this eight-digit alphanumeric code. It makes you a member of our SuperSlashShopper VIP Club, which entitles you to one emergency appointment at one of our offices for the next 6 weeks.”

“Well, I guess all I need is that skin screen.”

“Before you get undressed, would you like e-mail updates about our specials?”

“No thanks.”

“In that case, I'll tell you about them now. Refer a friend or family member and get 15% off any three products in our signature, private-label skin care line.”

“Okay. I'll see.”

“Removal of pigmented spots, half price?”

“No thanks.”

“Laser off two blood vessels, get the third one free?”

“Not interested.”

“How about a package of three photorejuvenation sessions at 20% off?”

“No, thank you. Wait. I just remembered, my wife needs help with a coleslaw recipe using low-fat mayonnaise.”

“Mayo Clinic, aisle 3. Cleveland Clinic, aisle 2. Well, thanks for coming.”

“Hold on. What about my skin screen?”

“Sorry, I forgot. Why did you want another one?”

“I'm tanned, guilty, and vulnerable.”

“Right. In that case you should see my colleague.”

“What colleague?”

“A psychiatrist. He's in fresh produce, behind the broccoli. Next!”

I gave my name at the front desk of my new eye doctor. “Check in around the corner,” said the clerk.

Two front desks, apparently. The secretary at the second one handed me some pages of demographics and medical history to fill out. In the meantime, she chatted with her associates as she scanned my insurance card.

I sat in the waiting room as instructed. After a short while, a young man called my name. Since the ophthalmologist is a middle-aged woman, I realized at once that he was someone else.

“Hi, I'm Jeff,” he said cheerily, ushering me into an exam room where he started to test my vision. (“What's the lowest line you can read? What's clearer—1 or 2? 3 or 4?”)

After a few minutes, I softened my voice and said, “Please don't be offended. But who are you?”

“I'm Jeff,” he explained.

“Yes, but what is your role here, exactly, Jeff?”

“I'm an ophthalmic technician,” he said. “The doctor will see you when I'm done examining you and dilating your pupils.”

He proceeded. In our time together, I learned a few things about Jeff. (I'm nosy that way.) Being an ophthalmic tech was his second career. His first was building custom furniture, “until I blew out my shoulder helping a buddy on a weekend.” Jeff's first eye job was in the cornea department of a teaching hospital, until slow business there limited his advancement options. So far he liked private practice. He tapped clinical data onto the computer screen to his left.

I returned to the waiting room. Shortly after, I heard my name again and through a dilated blur recognized the doctor herself. Her examination was businesslike, punctuated by more taps of data onto the screen. “You have early cataracts,” she said. “Not clinically significant yet, but they are there.” She said I didn't need new glasses unless I wanted a different style. “See you in a year,” she said, exiting. I made that appointment at the first front desk.

There are many aspects that go into a good or service. There are codes for diagnosis and procedure; these generate a fee. There are measures of efficiency and outcome aiming to streamline medical services, make them uniform, and lately, rate those who provide them. Much power and money are at stake, not to mention quality, now being energetically defined.

It's therefore understandable that for these and other reasons, many doctors delegate history taking to medical assistants, then counseling to other personnel. The doctor just comes in for the core service, the part that counts.

This seems a shame, for reasons I think go beyond sentiment, though maybe I'm fooling myself. (Without knowing the patient's background, level of motivation, and attitude toward the recommended regimen, how do you know he or she will follow it?) But larger forces at play outweigh objections like these.

Anyhow, in my own small clinical domain, I can still learn some personal things about my patients, and act as though it matters. After all, I've known many of them for a long time, some for decades.

My own internist of 25 years limited his panel and joined a national concierge firm. A colleague upstairs agreed to take me on despite a closed practice. Stan, in practice since the mid-1970's, is one of only three physicians who's been in my building longer than I have. He is quite a throwback. He has a small office, one secretary, and takes the medical history himself (no sheets). He even does his own EKG's, if you can believe it. But he does use e-mail and responds promptly.

You get the feeling that Stan actually knows who his patients are.

Stan is a vigorous guy, and he looks to practice another 5 years. Once he hangs 'em up, I figure I'll find a concierge of my own. Sometimes when you want intimacy, or its illusion, you just have to pay for it.

I gave my name at the front desk of my new eye doctor. “Check in around the corner,” said the clerk.

Two front desks, apparently. The secretary at the second one handed me some pages of demographics and medical history to fill out. In the meantime, she chatted with her associates as she scanned my insurance card.

I sat in the waiting room as instructed. After a short while, a young man called my name. Since the ophthalmologist is a middle-aged woman, I realized at once that he was someone else.

“Hi, I'm Jeff,” he said cheerily, ushering me into an exam room where he started to test my vision. (“What's the lowest line you can read? What's clearer—1 or 2? 3 or 4?”)

After a few minutes, I softened my voice and said, “Please don't be offended. But who are you?”

“I'm Jeff,” he explained.

“Yes, but what is your role here, exactly, Jeff?”

“I'm an ophthalmic technician,” he said. “The doctor will see you when I'm done examining you and dilating your pupils.”

He proceeded. In our time together, I learned a few things about Jeff. (I'm nosy that way.) Being an ophthalmic tech was his second career. His first was building custom furniture, “until I blew out my shoulder helping a buddy on a weekend.” Jeff's first eye job was in the cornea department of a teaching hospital, until slow business there limited his advancement options. So far he liked private practice. He tapped clinical data onto the computer screen to his left.

I returned to the waiting room. Shortly after, I heard my name again and through a dilated blur recognized the doctor herself. Her examination was businesslike, punctuated by more taps of data onto the screen. “You have early cataracts,” she said. “Not clinically significant yet, but they are there.” She said I didn't need new glasses unless I wanted a different style. “See you in a year,” she said, exiting. I made that appointment at the first front desk.

There are many aspects that go into a good or service. There are codes for diagnosis and procedure; these generate a fee. There are measures of efficiency and outcome aiming to streamline medical services, make them uniform, and lately, rate those who provide them. Much power and money are at stake, not to mention quality, now being energetically defined.

It's therefore understandable that for these and other reasons, many doctors delegate history taking to medical assistants, then counseling to other personnel. The doctor just comes in for the core service, the part that counts.

This seems a shame, for reasons I think go beyond sentiment, though maybe I'm fooling myself. (Without knowing the patient's background, level of motivation, and attitude toward the recommended regimen, how do you know he or she will follow it?) But larger forces at play outweigh objections like these.

Anyhow, in my own small clinical domain, I can still learn some personal things about my patients, and act as though it matters. After all, I've known many of them for a long time, some for decades.

My own internist of 25 years limited his panel and joined a national concierge firm. A colleague upstairs agreed to take me on despite a closed practice. Stan, in practice since the mid-1970's, is one of only three physicians who's been in my building longer than I have. He is quite a throwback. He has a small office, one secretary, and takes the medical history himself (no sheets). He even does his own EKG's, if you can believe it. But he does use e-mail and responds promptly.

You get the feeling that Stan actually knows who his patients are.

Stan is a vigorous guy, and he looks to practice another 5 years. Once he hangs 'em up, I figure I'll find a concierge of my own. Sometimes when you want intimacy, or its illusion, you just have to pay for it.

I gave my name at the front desk of my new eye doctor. “Check in around the corner,” said the clerk.

Two front desks, apparently. The secretary at the second one handed me some pages of demographics and medical history to fill out. In the meantime, she chatted with her associates as she scanned my insurance card.

I sat in the waiting room as instructed. After a short while, a young man called my name. Since the ophthalmologist is a middle-aged woman, I realized at once that he was someone else.

“Hi, I'm Jeff,” he said cheerily, ushering me into an exam room where he started to test my vision. (“What's the lowest line you can read? What's clearer—1 or 2? 3 or 4?”)

After a few minutes, I softened my voice and said, “Please don't be offended. But who are you?”

“I'm Jeff,” he explained.

“Yes, but what is your role here, exactly, Jeff?”

“I'm an ophthalmic technician,” he said. “The doctor will see you when I'm done examining you and dilating your pupils.”

He proceeded. In our time together, I learned a few things about Jeff. (I'm nosy that way.) Being an ophthalmic tech was his second career. His first was building custom furniture, “until I blew out my shoulder helping a buddy on a weekend.” Jeff's first eye job was in the cornea department of a teaching hospital, until slow business there limited his advancement options. So far he liked private practice. He tapped clinical data onto the computer screen to his left.

I returned to the waiting room. Shortly after, I heard my name again and through a dilated blur recognized the doctor herself. Her examination was businesslike, punctuated by more taps of data onto the screen. “You have early cataracts,” she said. “Not clinically significant yet, but they are there.” She said I didn't need new glasses unless I wanted a different style. “See you in a year,” she said, exiting. I made that appointment at the first front desk.

There are many aspects that go into a good or service. There are codes for diagnosis and procedure; these generate a fee. There are measures of efficiency and outcome aiming to streamline medical services, make them uniform, and lately, rate those who provide them. Much power and money are at stake, not to mention quality, now being energetically defined.

It's therefore understandable that for these and other reasons, many doctors delegate history taking to medical assistants, then counseling to other personnel. The doctor just comes in for the core service, the part that counts.

This seems a shame, for reasons I think go beyond sentiment, though maybe I'm fooling myself. (Without knowing the patient's background, level of motivation, and attitude toward the recommended regimen, how do you know he or she will follow it?) But larger forces at play outweigh objections like these.

Anyhow, in my own small clinical domain, I can still learn some personal things about my patients, and act as though it matters. After all, I've known many of them for a long time, some for decades.

My own internist of 25 years limited his panel and joined a national concierge firm. A colleague upstairs agreed to take me on despite a closed practice. Stan, in practice since the mid-1970's, is one of only three physicians who's been in my building longer than I have. He is quite a throwback. He has a small office, one secretary, and takes the medical history himself (no sheets). He even does his own EKG's, if you can believe it. But he does use e-mail and responds promptly.

You get the feeling that Stan actually knows who his patients are.

Stan is a vigorous guy, and he looks to practice another 5 years. Once he hangs 'em up, I figure I'll find a concierge of my own. Sometimes when you want intimacy, or its illusion, you just have to pay for it.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

Chuck's palms are rough and thick. “This started when I cut one palm at my job,” he said. “I work at a nuclear plant.”

I tell Chuck he has psoriasis, adding that the cut may have triggered its onset but hasn't caused its persistence, much less its appearance on the other palm. “Also,” I say, “radioactivity has nothing to do with it.”

“You mean I won't glow in the dark?” Chuck laughs nervously.

A few years ago, I pointed out some ways symptoms can have private meanings that make them more disturbing or threatening than one would expect. There is a short list of illness narratives that apply to most everyone, including I caught this; I'm allergic to that; trauma damaged me and made me weak; I have cancer inside; and I've grown old.

But sometimes there are special circumstances, unique to a particular person, that make these general concerns even more pointed than usual. Chuck's basic worry is that the cut on his palm brought on his problem. Had it been a splinter, he wouldn't care much—just some roughness that makes it awkward to shake hands sometimes. But what if the splinter is radioactive? That means every time his scaliness comes back, worsens, or fails to go away when treated—he'll glow in the dark. Creams will help Chuck. Undoing his narrative will help even more.

Or consider Becky. Her lips are red and scaly and are resistant to topical therapy. This is common enough and worthy of concern. Her lips look and feel funny, and she keeps licking them, which makes them worse. People can see the problem, which is embarrassing, especially because lip problems have sexual overtones. But Becky's worries are special to her.

“I work in a brewery,” she says. “If this is some kind of yeast infection, maybe it has something to do with beer and I'll have to give up my job.”

I have to confess that I don't routinely ask, “Do you work in a brewery and fear for your job?” Maybe I should. But when Becky brings the question up, she helps me understand what—for her, at least—is the central issue. She could live with some scaling and redness, she might even be able to ignore the lips long enough to stop licking them once she knows that every return of symptoms doesn't mean unemployment and retraining.

Personal angles like these come up all the time. Given a minute or two, patients bring them up all by themselves. Like Phil, who has a keloid on his chest. He's a middle-aged guy who doesn't seem likely to take his shirt off much. What bothers him about it? Appearance? Fear of cancer?

“I'm a courier for a clinical lab,” he explains, “so I'm in and out of the car all the time. And every time I fasten my seat belt it rubs this and it hurts.”

So that's it—fear of trauma (frequent rubbing could cause cancer, and so forth), but of a very specific, and unavoidable, sort. Easy to address, once you know what the worry is.

But the prize in my recent experience goes to Harold, who presents with a fairly large epidermoid cyst on his back. A common enough complaint—why is it there, is it a tumor, and so on. But Harold too has something particular in mind.

“The bump hurts when I take part in medieval recreations,” he says.

“You mean like the Society for Creative Anachronism?” I exclaim.

“Exactly,” says Harold.

That group, in case you're unfamiliar with it, is devoted to re-creating the Middle Ages in authentic detail. These folks put a lot of effort into getting everything just right. This means that his cyst bothers Harold because it rubs against his armor.

So he has two choices: to remove the cyst or to wear flexible armor, which wouldn't be authentic. So he really has only one choice.

I am not suggesting that we all add questions like, “Are you afraid you're radioactive?” or “Do you joust?” to our standard repertoire. But listening to patients' sometimes idiosyncratic personal spin on their symptoms and fears can be illuminating and helpful. Not to mention bemusing.

As a senior medical student, I spent an outpatient January in the office of a suburban pediatrician who cared for the children of many doctors.

After the holidays, he mused about the onslaught of gifts that he received from people to whom he extended professional courtesy.

Some gave him conventional things—candy, wine, and so forth. Others aimed for something more grandiose. Like the one who the year before had sent him a side of beef.

This is the season when many people get to ponder the intricacies of giving and getting gifts. Knowing when and what to give, as well as how to accept, requires a lot of art and sensitivity. (“That's exactly what I wanted! How did you know?”)

Thankfully, such subtleties are less important for doctors, at least at work, now that health insurance and fixed copayments have made most professional courtesy obsolete. I doubt many miss it. Professional relationships work best when objectivity is not undercut by other considerations. Like handouts.

Gifts haven't gone away, though, even if we're going to have to do without pens, mugs, and sticky notes from pharmaceutical companies. Some of my patients still like to bring presents. One Russian patient handed me a box of chocolates covered in Cyrillic script and funky Russian, ruby-red graphics. I protested that she really shouldn't have (though of course not too strongly, so as not to offend). Bringing the gift clearly makes her happy, and my staff eats the chocolate.

Many of my Russian patients like to bring gifts. Besides chocolate, they present wine and other spirits. One Russian physician brought a bottle of Armenian vodka in a bottle whose odd shape I couldn't make any sense of until he showed me how to hold it: It was shaped like a boxing glove! I show it to house guests, but it's just too weird for me to open. (Some time later I saw another vodka bottle from the former Soviet Union, this one shaped like a submachine gun.)

Other ethnic groups bring presents too. A Chinese patient generally brings cookies from Chinatown, and sometimes tea. Pamela brings a loaf of Irish bread every time she comes for Botox. She says she knows how much I like it.

I have no idea how she could know this, since I have never eaten an Irish bread, but I don't have the heart to tell her. My head nurse, Faye, grew up in South Boston. (If you can't locate Southie on the physical and cultural map, check out Matt Damon in “Good Will Hunting.”) Faye likes Irish bread, including Pamela's.

So far the examples I've given reflect varieties of ethnic expression and traditional patterns of gift-giving left over from old countries. Other presents are personal expressions—authors bring in a copy of their latest book, musicians drop off a CD. One patient last year brought an art calendar her mother had illustrated. A very elderly gentleman came by a few years ago, and reminded me that I had seen him decades before when I first went into practice. In his 90s, he was still busy making mobiles, and he brought me one. I couldn't bear to throw it out but had no idea what to do with it, so I hung it behind a door for a long time. Eventually, like most such things, it went.

Then some gifts, like their givers, are just, well, odd. One gentleman came a few years ago for a minor problem that cleared by the second visit. Before he left, he rather solemnly announced that he was so grateful for my intervention that he had purchased a gift. He reached into a tin bucket he'd brought and withdrew a short, green brush, the kind you use to wash dishes, and presented it to me. The price tag was still attached—49 cents.

I was speechless. I still am. The gift brush sits on my window sill, reminding me of the importance of going the extra mile for patients, of washing dishes, and of buying things on sale.

Hope you had happy holidays (and got the gifts you wanted)!

As a senior medical student, I spent an outpatient January in the office of a suburban pediatrician who cared for the children of many doctors.

After the holidays, he mused about the onslaught of gifts that he received from people to whom he extended professional courtesy.

Some gave him conventional things—candy, wine, and so forth. Others aimed for something more grandiose. Like the one who the year before had sent him a side of beef.

This is the season when many people get to ponder the intricacies of giving and getting gifts. Knowing when and what to give, as well as how to accept, requires a lot of art and sensitivity. (“That's exactly what I wanted! How did you know?”)

Thankfully, such subtleties are less important for doctors, at least at work, now that health insurance and fixed copayments have made most professional courtesy obsolete. I doubt many miss it. Professional relationships work best when objectivity is not undercut by other considerations. Like handouts.

Gifts haven't gone away, though, even if we're going to have to do without pens, mugs, and sticky notes from pharmaceutical companies. Some of my patients still like to bring presents. One Russian patient handed me a box of chocolates covered in Cyrillic script and funky Russian, ruby-red graphics. I protested that she really shouldn't have (though of course not too strongly, so as not to offend). Bringing the gift clearly makes her happy, and my staff eats the chocolate.

Many of my Russian patients like to bring gifts. Besides chocolate, they present wine and other spirits. One Russian physician brought a bottle of Armenian vodka in a bottle whose odd shape I couldn't make any sense of until he showed me how to hold it: It was shaped like a boxing glove! I show it to house guests, but it's just too weird for me to open. (Some time later I saw another vodka bottle from the former Soviet Union, this one shaped like a submachine gun.)

Other ethnic groups bring presents too. A Chinese patient generally brings cookies from Chinatown, and sometimes tea. Pamela brings a loaf of Irish bread every time she comes for Botox. She says she knows how much I like it.

I have no idea how she could know this, since I have never eaten an Irish bread, but I don't have the heart to tell her. My head nurse, Faye, grew up in South Boston. (If you can't locate Southie on the physical and cultural map, check out Matt Damon in “Good Will Hunting.”) Faye likes Irish bread, including Pamela's.

So far the examples I've given reflect varieties of ethnic expression and traditional patterns of gift-giving left over from old countries. Other presents are personal expressions—authors bring in a copy of their latest book, musicians drop off a CD. One patient last year brought an art calendar her mother had illustrated. A very elderly gentleman came by a few years ago, and reminded me that I had seen him decades before when I first went into practice. In his 90s, he was still busy making mobiles, and he brought me one. I couldn't bear to throw it out but had no idea what to do with it, so I hung it behind a door for a long time. Eventually, like most such things, it went.

Then some gifts, like their givers, are just, well, odd. One gentleman came a few years ago for a minor problem that cleared by the second visit. Before he left, he rather solemnly announced that he was so grateful for my intervention that he had purchased a gift. He reached into a tin bucket he'd brought and withdrew a short, green brush, the kind you use to wash dishes, and presented it to me. The price tag was still attached—49 cents.

I was speechless. I still am. The gift brush sits on my window sill, reminding me of the importance of going the extra mile for patients, of washing dishes, and of buying things on sale.

Hope you had happy holidays (and got the gifts you wanted)!

As a senior medical student, I spent an outpatient January in the office of a suburban pediatrician who cared for the children of many doctors.

After the holidays, he mused about the onslaught of gifts that he received from people to whom he extended professional courtesy.

Some gave him conventional things—candy, wine, and so forth. Others aimed for something more grandiose. Like the one who the year before had sent him a side of beef.

This is the season when many people get to ponder the intricacies of giving and getting gifts. Knowing when and what to give, as well as how to accept, requires a lot of art and sensitivity. (“That's exactly what I wanted! How did you know?”)

Thankfully, such subtleties are less important for doctors, at least at work, now that health insurance and fixed copayments have made most professional courtesy obsolete. I doubt many miss it. Professional relationships work best when objectivity is not undercut by other considerations. Like handouts.

Gifts haven't gone away, though, even if we're going to have to do without pens, mugs, and sticky notes from pharmaceutical companies. Some of my patients still like to bring presents. One Russian patient handed me a box of chocolates covered in Cyrillic script and funky Russian, ruby-red graphics. I protested that she really shouldn't have (though of course not too strongly, so as not to offend). Bringing the gift clearly makes her happy, and my staff eats the chocolate.

Many of my Russian patients like to bring gifts. Besides chocolate, they present wine and other spirits. One Russian physician brought a bottle of Armenian vodka in a bottle whose odd shape I couldn't make any sense of until he showed me how to hold it: It was shaped like a boxing glove! I show it to house guests, but it's just too weird for me to open. (Some time later I saw another vodka bottle from the former Soviet Union, this one shaped like a submachine gun.)

Other ethnic groups bring presents too. A Chinese patient generally brings cookies from Chinatown, and sometimes tea. Pamela brings a loaf of Irish bread every time she comes for Botox. She says she knows how much I like it.

I have no idea how she could know this, since I have never eaten an Irish bread, but I don't have the heart to tell her. My head nurse, Faye, grew up in South Boston. (If you can't locate Southie on the physical and cultural map, check out Matt Damon in “Good Will Hunting.”) Faye likes Irish bread, including Pamela's.

So far the examples I've given reflect varieties of ethnic expression and traditional patterns of gift-giving left over from old countries. Other presents are personal expressions—authors bring in a copy of their latest book, musicians drop off a CD. One patient last year brought an art calendar her mother had illustrated. A very elderly gentleman came by a few years ago, and reminded me that I had seen him decades before when I first went into practice. In his 90s, he was still busy making mobiles, and he brought me one. I couldn't bear to throw it out but had no idea what to do with it, so I hung it behind a door for a long time. Eventually, like most such things, it went.

Then some gifts, like their givers, are just, well, odd. One gentleman came a few years ago for a minor problem that cleared by the second visit. Before he left, he rather solemnly announced that he was so grateful for my intervention that he had purchased a gift. He reached into a tin bucket he'd brought and withdrew a short, green brush, the kind you use to wash dishes, and presented it to me. The price tag was still attached—49 cents.

I was speechless. I still am. The gift brush sits on my window sill, reminding me of the importance of going the extra mile for patients, of washing dishes, and of buying things on sale.

Hope you had happy holidays (and got the gifts you wanted)!