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Typhoid isn’t covered??!!
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Educational innovation
My son’s in medical school,” Fred told me. “First year.”
“Which school?”
Fred named a newly-chartered one.
“Really innovative curriculum,” he said.
“He got into a different school, too,” he said, “but he didn’t like how that school had canceled all lectures. Students just watch the lecture videos on their devices, so they scratched all the live ones.”
“Now that they don’t need lecturers, did they cut tuition?” I asked.
We both chuckled.
I was exposed to educational innovation on Day One of medical school, in the fall of 1968. (Go ahead, do the math.) The Dean addressed our entering class. “We’ve abolished tests,” he said. “We cut preclinical study from 2 years to 18 months, followed by one comprehensive exam.
"We want to get you into the clinic right away," he said, "because you chose to be doctors to help people. Even during the preclinical period, you’ll be getting not just dry frontal teaching but exposure to actual patients.”
We guessed that sounded good, especially the part about no tests. Less day-to-day studying. A lot less.
We still had lectures, of course, on biochemistry, anatomy, and so forth (they ran out of time and did all four extremities in 1 hour), but we felt little need to pay close attention. After all, any details we’d have to memorize would be diluted over three semesters, and 18 months was so far away.
As to the lectures themselves, I’ve never been diagnosed with actual narcolepsy, but when they turned out the lights and started showing slides, I fell fast asleep. Always have.
Most of us passed the comprehensive exam and moved on to the clinic. (We didn’t get into med school without knowing how to take tests, did we?)
The basic science faculty hated this educational innovation and recognized – correctly – that without tests we would take their classes less seriously. A couple of years later, the students themselves demanded that the tests be reinstated; lack of regular, numerical feedback made them anxious. So it was back to exams every 2 weeks. Poor devils.
Fast forward 40 years. Over lunch at a friend’s house, I recently met a young woman in her second year at a medical school in Chicago. “The school has an exciting, innovative curriculum,” she told me.
“No kidding,” I said. “What’s that?”
“They want to get us into the clinic as soon as possible,” she replied. “So they cut preclinical years to 18 months. And no regular tests. Just a comprehensive exam at the end. Much less day-to-day pressure.”
“Very innovative,” I observed.
***
Once in practice, I joined the clinical faculty of a local medical school. For 35 years, I hosted senior medical students for a month-long elective. During that time, I tried to pass on some of the things that weren’t on the standard academic curriculum. For instance, that patients have their own ideas about what is wrong with them, how it got that way, and what to do about it. That medical advice is less an order than a negotiation. Students seemed to find such notions – and their daily illustrations in the office – of some interest.
I put these and related deep thoughts between the covers of a book and sent a copy to the medical school registrar, from whom I had heard little over the years unless my student evaluations were 2 days late. My cover letter suggested that the school’s educators might be curious about what I’d been teaching their charges for 35 years.
The registrar replied by e-mail. “Thank you for your book,” she wrote. “I showed it to our dean of education, who told me that we would definitely not be changing our curriculum on the basis of your book. You might contact the medical librarian to see if they want to display it.”
I didn’t recall thinking, much less saying, that my ruminations ought to overturn the medical curriculum. I just thought they might be of some passing interest, coming as they did from an outside perspective.
Not so much, it turns out.
There are, in any event, so many exciting vistas of educational innovation to develop: genomics, precision medicine, and folding doctors into health care teams, and replacing clinical judgment with algorithms. The next generation of physicians, innovatively educated, will surpass all predecessors, just as we did.
Anyhow, they'll be bound to know more about the origins and insertions of the leg muscles. They could hardly know any less.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My son’s in medical school,” Fred told me. “First year.”
“Which school?”
Fred named a newly-chartered one.
“Really innovative curriculum,” he said.
“He got into a different school, too,” he said, “but he didn’t like how that school had canceled all lectures. Students just watch the lecture videos on their devices, so they scratched all the live ones.”
“Now that they don’t need lecturers, did they cut tuition?” I asked.
We both chuckled.
I was exposed to educational innovation on Day One of medical school, in the fall of 1968. (Go ahead, do the math.) The Dean addressed our entering class. “We’ve abolished tests,” he said. “We cut preclinical study from 2 years to 18 months, followed by one comprehensive exam.
"We want to get you into the clinic right away," he said, "because you chose to be doctors to help people. Even during the preclinical period, you’ll be getting not just dry frontal teaching but exposure to actual patients.”
We guessed that sounded good, especially the part about no tests. Less day-to-day studying. A lot less.
We still had lectures, of course, on biochemistry, anatomy, and so forth (they ran out of time and did all four extremities in 1 hour), but we felt little need to pay close attention. After all, any details we’d have to memorize would be diluted over three semesters, and 18 months was so far away.
As to the lectures themselves, I’ve never been diagnosed with actual narcolepsy, but when they turned out the lights and started showing slides, I fell fast asleep. Always have.
Most of us passed the comprehensive exam and moved on to the clinic. (We didn’t get into med school without knowing how to take tests, did we?)
The basic science faculty hated this educational innovation and recognized – correctly – that without tests we would take their classes less seriously. A couple of years later, the students themselves demanded that the tests be reinstated; lack of regular, numerical feedback made them anxious. So it was back to exams every 2 weeks. Poor devils.
Fast forward 40 years. Over lunch at a friend’s house, I recently met a young woman in her second year at a medical school in Chicago. “The school has an exciting, innovative curriculum,” she told me.
“No kidding,” I said. “What’s that?”
“They want to get us into the clinic as soon as possible,” she replied. “So they cut preclinical years to 18 months. And no regular tests. Just a comprehensive exam at the end. Much less day-to-day pressure.”
“Very innovative,” I observed.
***
Once in practice, I joined the clinical faculty of a local medical school. For 35 years, I hosted senior medical students for a month-long elective. During that time, I tried to pass on some of the things that weren’t on the standard academic curriculum. For instance, that patients have their own ideas about what is wrong with them, how it got that way, and what to do about it. That medical advice is less an order than a negotiation. Students seemed to find such notions – and their daily illustrations in the office – of some interest.
I put these and related deep thoughts between the covers of a book and sent a copy to the medical school registrar, from whom I had heard little over the years unless my student evaluations were 2 days late. My cover letter suggested that the school’s educators might be curious about what I’d been teaching their charges for 35 years.
The registrar replied by e-mail. “Thank you for your book,” she wrote. “I showed it to our dean of education, who told me that we would definitely not be changing our curriculum on the basis of your book. You might contact the medical librarian to see if they want to display it.”
I didn’t recall thinking, much less saying, that my ruminations ought to overturn the medical curriculum. I just thought they might be of some passing interest, coming as they did from an outside perspective.
Not so much, it turns out.
There are, in any event, so many exciting vistas of educational innovation to develop: genomics, precision medicine, and folding doctors into health care teams, and replacing clinical judgment with algorithms. The next generation of physicians, innovatively educated, will surpass all predecessors, just as we did.
Anyhow, they'll be bound to know more about the origins and insertions of the leg muscles. They could hardly know any less.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My son’s in medical school,” Fred told me. “First year.”
“Which school?”
Fred named a newly-chartered one.
“Really innovative curriculum,” he said.
“He got into a different school, too,” he said, “but he didn’t like how that school had canceled all lectures. Students just watch the lecture videos on their devices, so they scratched all the live ones.”
“Now that they don’t need lecturers, did they cut tuition?” I asked.
We both chuckled.
I was exposed to educational innovation on Day One of medical school, in the fall of 1968. (Go ahead, do the math.) The Dean addressed our entering class. “We’ve abolished tests,” he said. “We cut preclinical study from 2 years to 18 months, followed by one comprehensive exam.
"We want to get you into the clinic right away," he said, "because you chose to be doctors to help people. Even during the preclinical period, you’ll be getting not just dry frontal teaching but exposure to actual patients.”
We guessed that sounded good, especially the part about no tests. Less day-to-day studying. A lot less.
We still had lectures, of course, on biochemistry, anatomy, and so forth (they ran out of time and did all four extremities in 1 hour), but we felt little need to pay close attention. After all, any details we’d have to memorize would be diluted over three semesters, and 18 months was so far away.
As to the lectures themselves, I’ve never been diagnosed with actual narcolepsy, but when they turned out the lights and started showing slides, I fell fast asleep. Always have.
Most of us passed the comprehensive exam and moved on to the clinic. (We didn’t get into med school without knowing how to take tests, did we?)
The basic science faculty hated this educational innovation and recognized – correctly – that without tests we would take their classes less seriously. A couple of years later, the students themselves demanded that the tests be reinstated; lack of regular, numerical feedback made them anxious. So it was back to exams every 2 weeks. Poor devils.
Fast forward 40 years. Over lunch at a friend’s house, I recently met a young woman in her second year at a medical school in Chicago. “The school has an exciting, innovative curriculum,” she told me.
“No kidding,” I said. “What’s that?”
“They want to get us into the clinic as soon as possible,” she replied. “So they cut preclinical years to 18 months. And no regular tests. Just a comprehensive exam at the end. Much less day-to-day pressure.”
“Very innovative,” I observed.
***
Once in practice, I joined the clinical faculty of a local medical school. For 35 years, I hosted senior medical students for a month-long elective. During that time, I tried to pass on some of the things that weren’t on the standard academic curriculum. For instance, that patients have their own ideas about what is wrong with them, how it got that way, and what to do about it. That medical advice is less an order than a negotiation. Students seemed to find such notions – and their daily illustrations in the office – of some interest.
I put these and related deep thoughts between the covers of a book and sent a copy to the medical school registrar, from whom I had heard little over the years unless my student evaluations were 2 days late. My cover letter suggested that the school’s educators might be curious about what I’d been teaching their charges for 35 years.
The registrar replied by e-mail. “Thank you for your book,” she wrote. “I showed it to our dean of education, who told me that we would definitely not be changing our curriculum on the basis of your book. You might contact the medical librarian to see if they want to display it.”
I didn’t recall thinking, much less saying, that my ruminations ought to overturn the medical curriculum. I just thought they might be of some passing interest, coming as they did from an outside perspective.
Not so much, it turns out.
There are, in any event, so many exciting vistas of educational innovation to develop: genomics, precision medicine, and folding doctors into health care teams, and replacing clinical judgment with algorithms. The next generation of physicians, innovatively educated, will surpass all predecessors, just as we did.
Anyhow, they'll be bound to know more about the origins and insertions of the leg muscles. They could hardly know any less.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Whiskey bars and Painless Parker
Have you heard of Painless Parker? A flamboyant dentist from a century ago, Parker flouted professional propriety. He wore a top hat and performed what he claimed were painless extractions on street corners, advised by a marketer who once worked for P.T. Barnum. When his dental society objected to Parker’s claims, he legally changed his first name to “Painless.”
I thought of him this week, when a southwestern colleague sent me a glossy ad from a local magazine touting a new Dermatology Cosmetic and Laser Center. It featured “a luxury men’s lounge (Man-Cave), complete with whiskey bar.”
What, asked my correspondent, is our world coming to?
Whatever that is has been coming for some time. In Parker’s day, all professional advertising was frowned upon as unseemly. That injunction seems quaint now, when drug and hospital ads flood our TV screens and pop up on every website we visit.
Medical institutions of great prestige tell the world how the techniques they employ or pioneer lead to unsurpassed outcomes, how their patient-centered focus offers compassion second to none. They post YouTube videos in which academics highlight their expertise and their team’s empathy.
I am old enough to remember when such self-promotion was thought impolite and tasteless. I am also old enough to recall when telling the universe where you’ve been and showing pictures of what you’ve been up to was considered uncouth. Few of today’s young people, hooked on Facebook and Instagram, would have any idea why on earth anybody would think such things.
Aside from the presence or prospect of physical infirmity, growing old means being baffled by new attitudes and ways of doing things that younger folks understand implicitly.
In other words, getting old means accepting that you’re out of it.
This realization suggests to me an update of the Denver Developmental Screening Test of my pediatric youth. 3 months: roll over; 6 months: sit up; 12 months: walk; 50 years: join AARP; 70 years: decry the younger generation. (“Those millennials don’t want to work hard the way we did!”)
Some of us are entering the Golden Years of The-World-is-Going-to-Hell-in-a-Handbasket.
I accept that I will not understand or appreciate social media. Younger folk don’t really care what I think about that, or anything else. Even I don’t care what I think.
Fifteen years ago, I sat late one evening in the elegant, high-ceilinged lobby of a major area medical center. A close friend was dying upstairs after a failed second liver transplant for biliary cirrhosis, the first of which had given her 10 good years.
Absorbed in thought, I leaned back and looked up. Hanging from the ceiling was a banner: “Rated Number 3 in the U.S. for Nephrology by U.S. News and World Report!”
Great, I thought. What number are they for GI?
In the nearly 40 years I’ve worked in dermatology, our field has indeed changed. Cosmetic procedures and skin care products have taken on significant, sometimes dominant roles in various settings. Some changes seem excessive at first, even shady: Botox parties in private homes? Really? With time, these come to feel normal. Man caves and whiskey bars? If the public wants them, maybe they’re the new normal.
Cole Porter wrote:
“In olden days, a glimpse of stocking
Was looked on as something shocking.
But now, God knows,
Anything goes.”
He wrote those lines 80 years ago.
Painless Parker’s self-promotion helped bring some positive changes in professional practice. Pitching to the public means that the profession cares what patients think. Back in the decorous, prudish, paternalistic old days, that was often not the case; the patient was supposed to accept whatever the experts offered and just shut up.
Trying to turn back the tide of social change is as useful as old King Canute trying to turn back the tide on the beach – an effort as pathetic as it is futile. As we age, older folks tend to become faintly ridiculous anyway. Why add negatives you can avoid?
Our office has a large exam room that’s not fully used. It contains a lightly used UVB unit.
Add comfy sofas? High-def flat-screen TVs? The NFL Network? Cigars and single-malt? What say you, colleagues?
Call me Ritzy Rockoff. It sings!
Death might not be proud, but I bet old Painless would.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Have you heard of Painless Parker? A flamboyant dentist from a century ago, Parker flouted professional propriety. He wore a top hat and performed what he claimed were painless extractions on street corners, advised by a marketer who once worked for P.T. Barnum. When his dental society objected to Parker’s claims, he legally changed his first name to “Painless.”
I thought of him this week, when a southwestern colleague sent me a glossy ad from a local magazine touting a new Dermatology Cosmetic and Laser Center. It featured “a luxury men’s lounge (Man-Cave), complete with whiskey bar.”
What, asked my correspondent, is our world coming to?
Whatever that is has been coming for some time. In Parker’s day, all professional advertising was frowned upon as unseemly. That injunction seems quaint now, when drug and hospital ads flood our TV screens and pop up on every website we visit.
Medical institutions of great prestige tell the world how the techniques they employ or pioneer lead to unsurpassed outcomes, how their patient-centered focus offers compassion second to none. They post YouTube videos in which academics highlight their expertise and their team’s empathy.
I am old enough to remember when such self-promotion was thought impolite and tasteless. I am also old enough to recall when telling the universe where you’ve been and showing pictures of what you’ve been up to was considered uncouth. Few of today’s young people, hooked on Facebook and Instagram, would have any idea why on earth anybody would think such things.
Aside from the presence or prospect of physical infirmity, growing old means being baffled by new attitudes and ways of doing things that younger folks understand implicitly.
In other words, getting old means accepting that you’re out of it.
This realization suggests to me an update of the Denver Developmental Screening Test of my pediatric youth. 3 months: roll over; 6 months: sit up; 12 months: walk; 50 years: join AARP; 70 years: decry the younger generation. (“Those millennials don’t want to work hard the way we did!”)
Some of us are entering the Golden Years of The-World-is-Going-to-Hell-in-a-Handbasket.
I accept that I will not understand or appreciate social media. Younger folk don’t really care what I think about that, or anything else. Even I don’t care what I think.
Fifteen years ago, I sat late one evening in the elegant, high-ceilinged lobby of a major area medical center. A close friend was dying upstairs after a failed second liver transplant for biliary cirrhosis, the first of which had given her 10 good years.
Absorbed in thought, I leaned back and looked up. Hanging from the ceiling was a banner: “Rated Number 3 in the U.S. for Nephrology by U.S. News and World Report!”
Great, I thought. What number are they for GI?
In the nearly 40 years I’ve worked in dermatology, our field has indeed changed. Cosmetic procedures and skin care products have taken on significant, sometimes dominant roles in various settings. Some changes seem excessive at first, even shady: Botox parties in private homes? Really? With time, these come to feel normal. Man caves and whiskey bars? If the public wants them, maybe they’re the new normal.
Cole Porter wrote:
“In olden days, a glimpse of stocking
Was looked on as something shocking.
But now, God knows,
Anything goes.”
He wrote those lines 80 years ago.
Painless Parker’s self-promotion helped bring some positive changes in professional practice. Pitching to the public means that the profession cares what patients think. Back in the decorous, prudish, paternalistic old days, that was often not the case; the patient was supposed to accept whatever the experts offered and just shut up.
Trying to turn back the tide of social change is as useful as old King Canute trying to turn back the tide on the beach – an effort as pathetic as it is futile. As we age, older folks tend to become faintly ridiculous anyway. Why add negatives you can avoid?
Our office has a large exam room that’s not fully used. It contains a lightly used UVB unit.
Add comfy sofas? High-def flat-screen TVs? The NFL Network? Cigars and single-malt? What say you, colleagues?
Call me Ritzy Rockoff. It sings!
Death might not be proud, but I bet old Painless would.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Have you heard of Painless Parker? A flamboyant dentist from a century ago, Parker flouted professional propriety. He wore a top hat and performed what he claimed were painless extractions on street corners, advised by a marketer who once worked for P.T. Barnum. When his dental society objected to Parker’s claims, he legally changed his first name to “Painless.”
I thought of him this week, when a southwestern colleague sent me a glossy ad from a local magazine touting a new Dermatology Cosmetic and Laser Center. It featured “a luxury men’s lounge (Man-Cave), complete with whiskey bar.”
What, asked my correspondent, is our world coming to?
Whatever that is has been coming for some time. In Parker’s day, all professional advertising was frowned upon as unseemly. That injunction seems quaint now, when drug and hospital ads flood our TV screens and pop up on every website we visit.
Medical institutions of great prestige tell the world how the techniques they employ or pioneer lead to unsurpassed outcomes, how their patient-centered focus offers compassion second to none. They post YouTube videos in which academics highlight their expertise and their team’s empathy.
I am old enough to remember when such self-promotion was thought impolite and tasteless. I am also old enough to recall when telling the universe where you’ve been and showing pictures of what you’ve been up to was considered uncouth. Few of today’s young people, hooked on Facebook and Instagram, would have any idea why on earth anybody would think such things.
Aside from the presence or prospect of physical infirmity, growing old means being baffled by new attitudes and ways of doing things that younger folks understand implicitly.
In other words, getting old means accepting that you’re out of it.
This realization suggests to me an update of the Denver Developmental Screening Test of my pediatric youth. 3 months: roll over; 6 months: sit up; 12 months: walk; 50 years: join AARP; 70 years: decry the younger generation. (“Those millennials don’t want to work hard the way we did!”)
Some of us are entering the Golden Years of The-World-is-Going-to-Hell-in-a-Handbasket.
I accept that I will not understand or appreciate social media. Younger folk don’t really care what I think about that, or anything else. Even I don’t care what I think.
Fifteen years ago, I sat late one evening in the elegant, high-ceilinged lobby of a major area medical center. A close friend was dying upstairs after a failed second liver transplant for biliary cirrhosis, the first of which had given her 10 good years.
Absorbed in thought, I leaned back and looked up. Hanging from the ceiling was a banner: “Rated Number 3 in the U.S. for Nephrology by U.S. News and World Report!”
Great, I thought. What number are they for GI?
In the nearly 40 years I’ve worked in dermatology, our field has indeed changed. Cosmetic procedures and skin care products have taken on significant, sometimes dominant roles in various settings. Some changes seem excessive at first, even shady: Botox parties in private homes? Really? With time, these come to feel normal. Man caves and whiskey bars? If the public wants them, maybe they’re the new normal.
Cole Porter wrote:
“In olden days, a glimpse of stocking
Was looked on as something shocking.
But now, God knows,
Anything goes.”
He wrote those lines 80 years ago.
Painless Parker’s self-promotion helped bring some positive changes in professional practice. Pitching to the public means that the profession cares what patients think. Back in the decorous, prudish, paternalistic old days, that was often not the case; the patient was supposed to accept whatever the experts offered and just shut up.
Trying to turn back the tide of social change is as useful as old King Canute trying to turn back the tide on the beach – an effort as pathetic as it is futile. As we age, older folks tend to become faintly ridiculous anyway. Why add negatives you can avoid?
Our office has a large exam room that’s not fully used. It contains a lightly used UVB unit.
Add comfy sofas? High-def flat-screen TVs? The NFL Network? Cigars and single-malt? What say you, colleagues?
Call me Ritzy Rockoff. It sings!
Death might not be proud, but I bet old Painless would.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Swiss freedom, hidden witnesses, and beer
Most of medical practice is mundane. Just a few interesting cases pass through now and then to break up the clinical routine, a rhythm that’s fine with me.
More often, patients expand my vistas by telling me about places I’ve never been and things I didn’t know and couldn’t imagine. Sometimes these tales are even more riveting than atopic dermatitis or mildly dysplastic nevi. Learning about them leaves me smiling and scratching my head. What will they tell me about next?
“I always come to Boston around this time,” she said. “But today I actually am celebrating Swiss National Day.”
“No kidding,” I said. “What is Swiss National Day?”
“We commemorate the founding of Switzerland in 1291,” she said.
“And how do you celebrate it?” I asked.
“Well, we are Swiss,” she said, “so we work all day. Then we have a party in the evening.
“That is how it used to be anyway,” she said. “About 40 years ago, the parties on the left and right made a deal and established two holidays: Labor Day on May 1st and the National Holiday on August 1st. Now we get those whole days off.”
“Which was the end of Swiss civilization as we know it,” I suggested.
“That’s exactly what my father said when it happened,” said Valentina, with a restrained, Swiss smile. “But somehow life goes on for us, even with 2 days a year off.”
* * * * * * * * * * * * * * * * * * * * * * *
When I picked up his chart, I saw that my patient’s last name suggested that he hailed from one of the countries left after the breakup of Yugoslavia. We’ll call him Magovcevic.
As soon as I walked in, however, it was clear that wherever he came from was nowhere near Serbia. His features and accent were Brazilian.
“I come from Minas Gerais,” he said, “in the South, not far from Rio.”
“So how come you have a Slavic name?” I asked him.
“My parents had a different last name,” he said.
“Then how did you come to be called Magovcevic?” I asked.
“I’m in the witness protection program,” he said.
I had to hold onto the sink to stay upright. Of all the possible responses he could have made, that one was not on my list.
“Did you pick the name yourself?” I asked. I don’t think I’d ever given a thought to how family names are chosen for people in witness protection.
“No, they gave it to me,” he said. “I was still a minor.”
At that point I stopped asking questions. Whatever it was that he witnessed as a minor that landed him in witness protection I didn’t want to know about.
* * * * * * * * * * * * * * * * * * * * * * *
Myrna was very happy to tell me that her son was doing well in college and had a good summer job.
“He works in a beer garden downtown,” she said. “The tips are great.”
“What is he studying in school?” I asked.
“Fermentation studies,” she replied.
After she’d said he was moonlighting in a beer garden, I thought she was pulling my leg. I know college students have keg parties after class, but I didn’t know they studied what goes into the kegs during class.
But Myrna was serious. “He’s interested in biochemistry,” she explained. “He wants to focus on developing better beers.”
A younger colleague whom I told about this chuckled at my perplexity. “Sure,” she said, “fermentation studies is the hot new field. Lots of people are getting into it.”
I have long since resigned myself to being clueless about what younger people are into, especially social media. But I found myself bemused at how it just never occurred to me that bright young biochemists might burn with ambition to bring the world better craft beers.
I have since learned that fermentation studies have other applications too. Like wine. And wine, like cosmetics, has been around a lot longer than dermatology.
* * * * * * * * * * * * * * * * * * * * * * *
Skin is interesting, but the people inside it are often even more so. Who knows what I’ll run into tomorrow? I won’t even try to guess.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com.
Most of medical practice is mundane. Just a few interesting cases pass through now and then to break up the clinical routine, a rhythm that’s fine with me.
More often, patients expand my vistas by telling me about places I’ve never been and things I didn’t know and couldn’t imagine. Sometimes these tales are even more riveting than atopic dermatitis or mildly dysplastic nevi. Learning about them leaves me smiling and scratching my head. What will they tell me about next?
“I always come to Boston around this time,” she said. “But today I actually am celebrating Swiss National Day.”
“No kidding,” I said. “What is Swiss National Day?”
“We commemorate the founding of Switzerland in 1291,” she said.
“And how do you celebrate it?” I asked.
“Well, we are Swiss,” she said, “so we work all day. Then we have a party in the evening.
“That is how it used to be anyway,” she said. “About 40 years ago, the parties on the left and right made a deal and established two holidays: Labor Day on May 1st and the National Holiday on August 1st. Now we get those whole days off.”
“Which was the end of Swiss civilization as we know it,” I suggested.
“That’s exactly what my father said when it happened,” said Valentina, with a restrained, Swiss smile. “But somehow life goes on for us, even with 2 days a year off.”
* * * * * * * * * * * * * * * * * * * * * * *
When I picked up his chart, I saw that my patient’s last name suggested that he hailed from one of the countries left after the breakup of Yugoslavia. We’ll call him Magovcevic.
As soon as I walked in, however, it was clear that wherever he came from was nowhere near Serbia. His features and accent were Brazilian.
“I come from Minas Gerais,” he said, “in the South, not far from Rio.”
“So how come you have a Slavic name?” I asked him.
“My parents had a different last name,” he said.
“Then how did you come to be called Magovcevic?” I asked.
“I’m in the witness protection program,” he said.
I had to hold onto the sink to stay upright. Of all the possible responses he could have made, that one was not on my list.
“Did you pick the name yourself?” I asked. I don’t think I’d ever given a thought to how family names are chosen for people in witness protection.
“No, they gave it to me,” he said. “I was still a minor.”
At that point I stopped asking questions. Whatever it was that he witnessed as a minor that landed him in witness protection I didn’t want to know about.
* * * * * * * * * * * * * * * * * * * * * * *
Myrna was very happy to tell me that her son was doing well in college and had a good summer job.
“He works in a beer garden downtown,” she said. “The tips are great.”
“What is he studying in school?” I asked.
“Fermentation studies,” she replied.
After she’d said he was moonlighting in a beer garden, I thought she was pulling my leg. I know college students have keg parties after class, but I didn’t know they studied what goes into the kegs during class.
But Myrna was serious. “He’s interested in biochemistry,” she explained. “He wants to focus on developing better beers.”
A younger colleague whom I told about this chuckled at my perplexity. “Sure,” she said, “fermentation studies is the hot new field. Lots of people are getting into it.”
I have long since resigned myself to being clueless about what younger people are into, especially social media. But I found myself bemused at how it just never occurred to me that bright young biochemists might burn with ambition to bring the world better craft beers.
I have since learned that fermentation studies have other applications too. Like wine. And wine, like cosmetics, has been around a lot longer than dermatology.
* * * * * * * * * * * * * * * * * * * * * * *
Skin is interesting, but the people inside it are often even more so. Who knows what I’ll run into tomorrow? I won’t even try to guess.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com.
Most of medical practice is mundane. Just a few interesting cases pass through now and then to break up the clinical routine, a rhythm that’s fine with me.
More often, patients expand my vistas by telling me about places I’ve never been and things I didn’t know and couldn’t imagine. Sometimes these tales are even more riveting than atopic dermatitis or mildly dysplastic nevi. Learning about them leaves me smiling and scratching my head. What will they tell me about next?
“I always come to Boston around this time,” she said. “But today I actually am celebrating Swiss National Day.”
“No kidding,” I said. “What is Swiss National Day?”
“We commemorate the founding of Switzerland in 1291,” she said.
“And how do you celebrate it?” I asked.
“Well, we are Swiss,” she said, “so we work all day. Then we have a party in the evening.
“That is how it used to be anyway,” she said. “About 40 years ago, the parties on the left and right made a deal and established two holidays: Labor Day on May 1st and the National Holiday on August 1st. Now we get those whole days off.”
“Which was the end of Swiss civilization as we know it,” I suggested.
“That’s exactly what my father said when it happened,” said Valentina, with a restrained, Swiss smile. “But somehow life goes on for us, even with 2 days a year off.”
* * * * * * * * * * * * * * * * * * * * * * *
When I picked up his chart, I saw that my patient’s last name suggested that he hailed from one of the countries left after the breakup of Yugoslavia. We’ll call him Magovcevic.
As soon as I walked in, however, it was clear that wherever he came from was nowhere near Serbia. His features and accent were Brazilian.
“I come from Minas Gerais,” he said, “in the South, not far from Rio.”
“So how come you have a Slavic name?” I asked him.
“My parents had a different last name,” he said.
“Then how did you come to be called Magovcevic?” I asked.
“I’m in the witness protection program,” he said.
I had to hold onto the sink to stay upright. Of all the possible responses he could have made, that one was not on my list.
“Did you pick the name yourself?” I asked. I don’t think I’d ever given a thought to how family names are chosen for people in witness protection.
“No, they gave it to me,” he said. “I was still a minor.”
At that point I stopped asking questions. Whatever it was that he witnessed as a minor that landed him in witness protection I didn’t want to know about.
* * * * * * * * * * * * * * * * * * * * * * *
Myrna was very happy to tell me that her son was doing well in college and had a good summer job.
“He works in a beer garden downtown,” she said. “The tips are great.”
“What is he studying in school?” I asked.
“Fermentation studies,” she replied.
After she’d said he was moonlighting in a beer garden, I thought she was pulling my leg. I know college students have keg parties after class, but I didn’t know they studied what goes into the kegs during class.
But Myrna was serious. “He’s interested in biochemistry,” she explained. “He wants to focus on developing better beers.”
A younger colleague whom I told about this chuckled at my perplexity. “Sure,” she said, “fermentation studies is the hot new field. Lots of people are getting into it.”
I have long since resigned myself to being clueless about what younger people are into, especially social media. But I found myself bemused at how it just never occurred to me that bright young biochemists might burn with ambition to bring the world better craft beers.
I have since learned that fermentation studies have other applications too. Like wine. And wine, like cosmetics, has been around a lot longer than dermatology.
* * * * * * * * * * * * * * * * * * * * * * *
Skin is interesting, but the people inside it are often even more so. Who knows what I’ll run into tomorrow? I won’t even try to guess.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com.
Consulting for the dead
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Listening for golf balls
“What did the patient say about the golf ball?” I asked my student.
The student looked blank. “Golf ball?” he asked.
“The patient said a golf ball hit him.”
“He did?”
“I showed him a precancerous red spot on his forehead, and said I could freeze it off.”
“Yes,” said the student. “Now I remember.”
“Good. Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But in his 60 years, he’s been hit by a lot of things. How can he be sure the golf ball hit just that spot? And anyhow, why tell me about it? He must have thought it was important for me to know. We discussed this the other day,” I reminded him.
“Because there was trauma?”
“That’s it,” I said. “One way patients understand why things happen to them is by saying that what got sick was hit by something. They assume trauma weakens and damages the body, and disposes it to being unhealthy.
“After all,” I went on, “I had told him his spot was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot only right there? His answer: Sun damages all skin, but the part the golf ball whacked is especially susceptible.
“Is he right? I have no idea, but it’s important – to him – to think so. Not so much for this spot – we’re going to treat it anyway – but because of what he said 2 minutes later about his left shin. Remember?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just a seborrheic keratosis, not even precancerous. But he said he was always picking it.”
“Yes, he did say that,” said the student.
“So again: Why did he think I needed to know?”
“Because picking is a form of trauma, which might cause the spot to turn into something?”
“Yes, indeed,” I said. “You should train yourself to listen to these offhand remarks that seem irrelevant to you. They are relevant to the patient, or he wouldn’t say them.
Sure enough, a little later the student and I met another patient coming for a skin check. A computer scientist from a local university, he displayed a big collection of cherry angiomas on his torso, front, and back.
Looking at his belly, he said, “I know where I got those.”
“Which ones?” I asked.
He pointed to a dense collection of red spots near his navel. “A soccer ball hit me there when I was a teenager in Colombia,” he said.
Later, the student and I discussed this man’s recollection. “What makes his observation striking,” I suggested, “is not just as another example of a patient blaming body changes on trauma. It’s that he did it in a way that even a smidgen of critical thinking – the kind he applies to his professional work all the time – would show that his hypothesis makes no sense. After all, he has dozens of red spots nowhere near where the soccer ball supposedly hit him.
“You would think a computer scientist would notice this, but when it comes to looking at our own health, even sophisticated scientific training may not help. Instead, the thinking is: “I’ve got these red spots. Something caused them. A soccer ball hit me down there. That must be it.”
Sometimes hearing what patients say doesn’t matter; we’re not going to remove the cherry angiomas. But sometimes it does, by telling us the real reason they want something removed, which may include some guilt about their own picking, guilt they can do without.
But you would have to listen for that nuance, and listening is hard. Mostly, in medicine and in life, we hear only what we expect to hear.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected]
“What did the patient say about the golf ball?” I asked my student.
The student looked blank. “Golf ball?” he asked.
“The patient said a golf ball hit him.”
“He did?”
“I showed him a precancerous red spot on his forehead, and said I could freeze it off.”
“Yes,” said the student. “Now I remember.”
“Good. Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But in his 60 years, he’s been hit by a lot of things. How can he be sure the golf ball hit just that spot? And anyhow, why tell me about it? He must have thought it was important for me to know. We discussed this the other day,” I reminded him.
“Because there was trauma?”
“That’s it,” I said. “One way patients understand why things happen to them is by saying that what got sick was hit by something. They assume trauma weakens and damages the body, and disposes it to being unhealthy.
“After all,” I went on, “I had told him his spot was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot only right there? His answer: Sun damages all skin, but the part the golf ball whacked is especially susceptible.
“Is he right? I have no idea, but it’s important – to him – to think so. Not so much for this spot – we’re going to treat it anyway – but because of what he said 2 minutes later about his left shin. Remember?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just a seborrheic keratosis, not even precancerous. But he said he was always picking it.”
“Yes, he did say that,” said the student.
“So again: Why did he think I needed to know?”
“Because picking is a form of trauma, which might cause the spot to turn into something?”
“Yes, indeed,” I said. “You should train yourself to listen to these offhand remarks that seem irrelevant to you. They are relevant to the patient, or he wouldn’t say them.
Sure enough, a little later the student and I met another patient coming for a skin check. A computer scientist from a local university, he displayed a big collection of cherry angiomas on his torso, front, and back.
Looking at his belly, he said, “I know where I got those.”
“Which ones?” I asked.
He pointed to a dense collection of red spots near his navel. “A soccer ball hit me there when I was a teenager in Colombia,” he said.
Later, the student and I discussed this man’s recollection. “What makes his observation striking,” I suggested, “is not just as another example of a patient blaming body changes on trauma. It’s that he did it in a way that even a smidgen of critical thinking – the kind he applies to his professional work all the time – would show that his hypothesis makes no sense. After all, he has dozens of red spots nowhere near where the soccer ball supposedly hit him.
“You would think a computer scientist would notice this, but when it comes to looking at our own health, even sophisticated scientific training may not help. Instead, the thinking is: “I’ve got these red spots. Something caused them. A soccer ball hit me down there. That must be it.”
Sometimes hearing what patients say doesn’t matter; we’re not going to remove the cherry angiomas. But sometimes it does, by telling us the real reason they want something removed, which may include some guilt about their own picking, guilt they can do without.
But you would have to listen for that nuance, and listening is hard. Mostly, in medicine and in life, we hear only what we expect to hear.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected]
“What did the patient say about the golf ball?” I asked my student.
The student looked blank. “Golf ball?” he asked.
“The patient said a golf ball hit him.”
“He did?”
“I showed him a precancerous red spot on his forehead, and said I could freeze it off.”
“Yes,” said the student. “Now I remember.”
“Good. Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But in his 60 years, he’s been hit by a lot of things. How can he be sure the golf ball hit just that spot? And anyhow, why tell me about it? He must have thought it was important for me to know. We discussed this the other day,” I reminded him.
“Because there was trauma?”
“That’s it,” I said. “One way patients understand why things happen to them is by saying that what got sick was hit by something. They assume trauma weakens and damages the body, and disposes it to being unhealthy.
“After all,” I went on, “I had told him his spot was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot only right there? His answer: Sun damages all skin, but the part the golf ball whacked is especially susceptible.
“Is he right? I have no idea, but it’s important – to him – to think so. Not so much for this spot – we’re going to treat it anyway – but because of what he said 2 minutes later about his left shin. Remember?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just a seborrheic keratosis, not even precancerous. But he said he was always picking it.”
“Yes, he did say that,” said the student.
“So again: Why did he think I needed to know?”
“Because picking is a form of trauma, which might cause the spot to turn into something?”
“Yes, indeed,” I said. “You should train yourself to listen to these offhand remarks that seem irrelevant to you. They are relevant to the patient, or he wouldn’t say them.
Sure enough, a little later the student and I met another patient coming for a skin check. A computer scientist from a local university, he displayed a big collection of cherry angiomas on his torso, front, and back.
Looking at his belly, he said, “I know where I got those.”
“Which ones?” I asked.
He pointed to a dense collection of red spots near his navel. “A soccer ball hit me there when I was a teenager in Colombia,” he said.
Later, the student and I discussed this man’s recollection. “What makes his observation striking,” I suggested, “is not just as another example of a patient blaming body changes on trauma. It’s that he did it in a way that even a smidgen of critical thinking – the kind he applies to his professional work all the time – would show that his hypothesis makes no sense. After all, he has dozens of red spots nowhere near where the soccer ball supposedly hit him.
“You would think a computer scientist would notice this, but when it comes to looking at our own health, even sophisticated scientific training may not help. Instead, the thinking is: “I’ve got these red spots. Something caused them. A soccer ball hit me down there. That must be it.”
Sometimes hearing what patients say doesn’t matter; we’re not going to remove the cherry angiomas. But sometimes it does, by telling us the real reason they want something removed, which may include some guilt about their own picking, guilt they can do without.
But you would have to listen for that nuance, and listening is hard. Mostly, in medicine and in life, we hear only what we expect to hear.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected]
Keep a symptom diary!
A friend sent me an article from the New Yorker called “The Algorithm Will See You Now,” in which Siddhartha Mukherjee, MD, author of the magisterial “The Emperor of All Maladies,” ponders the effect artificial intelligence may have on medicine. One possible outcome may be that computers replace radiologists and dermatologists. (They already beat top humans at Jeopardy, chess, and Go, so why not lick Homo sapiens at pattern recognition?)
No worries for me. When Watson takes over, I will be off somewhere playing shuffleboard.
“It’s a particularly bad case. But, the question is why it appeared now, and why it’s getting worse.” She asked the patient about new hair products or family stress. The man said he’d just lost his job.
“Keep a diary,” she advised. “We can determine if there’s a link.”
Thus was my pedagogic legacy shattered in an instant. I’ve spent decades advising students not to tell patients they have a bad case of anything and never to ask them to keep diaries. Then, a foremost medical writer in a leading cultural journal endorses the reverse of both lessons. What was I thinking all these years?
I counseled students not to call any case “bad” because I saw how patients took it personally if I told them that. No matter how mild their diagnosis – rosacea and seborrhea, maladies less emperors than footmen– patients who heard theirs called “bad” looked sad, even insulted. Sad and insulted patients may give up and don’t follow treatment advice. (With such a bad case, why bother?) I didn’t urge patients to think that way. I just couldn’t ignore that they did. By contrast, assuring people that their case “wasn’t bad at all!” made them light up like Halloween pumpkins.
As for diaries, I’ve filed a few that patients handed me over the years. I showed these detailed chronicles to students to illustrate the lengths to which people will go to explain the unexplainable, like the ups and downs of idiopathic urticaria, eczema, and so forth:
- Thursday, August 6th, had sushi at a restaurant with friends.
- Sunday, September 3rd, watched science-fiction movie, unable to sleep that night.
- Monday, October 2nd, discarded fourth new detergent.
And so on.
In the meantime, several times each working day patients would troop in with randomly reoccurring conditions, atopic dermatitis above all, prompting dialogues like these:
“This is crazy! I never had anything like this before!”
“Well, actually, Ms. Jones, I treated you for the same thing in 2006.”
*********************
“This is bizarre! I never had this, and no one in my family ever did either.”
“I see. Well, here’s a prescription.”
“Come to think of it, my Mom had sensitive skin, and I get these dry patches on my arms and legs every winter.”
********************
“I’ve changed my soap three times and thrown out my makeup four times, and the rash keeps coming back. What should I do?”
“Stop throwing out your soap and makeup?”
And so on and on.
Sometimes, of course, semi-plausible causes seem to surface, such as stress. The question is, How useful is it to point this out? Consider the New Yorker case. Once the doctor “determined there is a link,” how might the conversation go?
“We have found the trigger, Mr. Smith. It’s stress.”
“Great! What should I do?”
“Don’t get laid off.”
No doctor (I hope) would ever say that, but patients present reports like the following all the time:
“As a kid, I was allergic to milk, but I’m not anymore.” (No, he wasn’t – he had infantile eczema that got blamed on milk.)
“Penicillin gave me hives.” (But, the hives lasted 6 weeks after the penicillin was stopped, which showed that the hives were idiopathic.)
“I’m very sensitive. I can’t use any moisturizer, any makeup, or all pills.” (People generate long litanies of sensitivities, piling one spurious correlation on another.)
Who benefits from “determining the link” when there isn’t any? Not the patients I’ve been seeing for forty years. Your patients? Maybe detergent manufacturers?
As to my errant pedagogy, with any luck, my students don’t remember a word I told them, a safe assumption for any teacher.
Either that or they don’t read the New Yorker.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
A friend sent me an article from the New Yorker called “The Algorithm Will See You Now,” in which Siddhartha Mukherjee, MD, author of the magisterial “The Emperor of All Maladies,” ponders the effect artificial intelligence may have on medicine. One possible outcome may be that computers replace radiologists and dermatologists. (They already beat top humans at Jeopardy, chess, and Go, so why not lick Homo sapiens at pattern recognition?)
No worries for me. When Watson takes over, I will be off somewhere playing shuffleboard.
“It’s a particularly bad case. But, the question is why it appeared now, and why it’s getting worse.” She asked the patient about new hair products or family stress. The man said he’d just lost his job.
“Keep a diary,” she advised. “We can determine if there’s a link.”
Thus was my pedagogic legacy shattered in an instant. I’ve spent decades advising students not to tell patients they have a bad case of anything and never to ask them to keep diaries. Then, a foremost medical writer in a leading cultural journal endorses the reverse of both lessons. What was I thinking all these years?
I counseled students not to call any case “bad” because I saw how patients took it personally if I told them that. No matter how mild their diagnosis – rosacea and seborrhea, maladies less emperors than footmen– patients who heard theirs called “bad” looked sad, even insulted. Sad and insulted patients may give up and don’t follow treatment advice. (With such a bad case, why bother?) I didn’t urge patients to think that way. I just couldn’t ignore that they did. By contrast, assuring people that their case “wasn’t bad at all!” made them light up like Halloween pumpkins.
As for diaries, I’ve filed a few that patients handed me over the years. I showed these detailed chronicles to students to illustrate the lengths to which people will go to explain the unexplainable, like the ups and downs of idiopathic urticaria, eczema, and so forth:
- Thursday, August 6th, had sushi at a restaurant with friends.
- Sunday, September 3rd, watched science-fiction movie, unable to sleep that night.
- Monday, October 2nd, discarded fourth new detergent.
And so on.
In the meantime, several times each working day patients would troop in with randomly reoccurring conditions, atopic dermatitis above all, prompting dialogues like these:
“This is crazy! I never had anything like this before!”
“Well, actually, Ms. Jones, I treated you for the same thing in 2006.”
*********************
“This is bizarre! I never had this, and no one in my family ever did either.”
“I see. Well, here’s a prescription.”
“Come to think of it, my Mom had sensitive skin, and I get these dry patches on my arms and legs every winter.”
********************
“I’ve changed my soap three times and thrown out my makeup four times, and the rash keeps coming back. What should I do?”
“Stop throwing out your soap and makeup?”
And so on and on.
Sometimes, of course, semi-plausible causes seem to surface, such as stress. The question is, How useful is it to point this out? Consider the New Yorker case. Once the doctor “determined there is a link,” how might the conversation go?
“We have found the trigger, Mr. Smith. It’s stress.”
“Great! What should I do?”
“Don’t get laid off.”
No doctor (I hope) would ever say that, but patients present reports like the following all the time:
“As a kid, I was allergic to milk, but I’m not anymore.” (No, he wasn’t – he had infantile eczema that got blamed on milk.)
“Penicillin gave me hives.” (But, the hives lasted 6 weeks after the penicillin was stopped, which showed that the hives were idiopathic.)
“I’m very sensitive. I can’t use any moisturizer, any makeup, or all pills.” (People generate long litanies of sensitivities, piling one spurious correlation on another.)
Who benefits from “determining the link” when there isn’t any? Not the patients I’ve been seeing for forty years. Your patients? Maybe detergent manufacturers?
As to my errant pedagogy, with any luck, my students don’t remember a word I told them, a safe assumption for any teacher.
Either that or they don’t read the New Yorker.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
A friend sent me an article from the New Yorker called “The Algorithm Will See You Now,” in which Siddhartha Mukherjee, MD, author of the magisterial “The Emperor of All Maladies,” ponders the effect artificial intelligence may have on medicine. One possible outcome may be that computers replace radiologists and dermatologists. (They already beat top humans at Jeopardy, chess, and Go, so why not lick Homo sapiens at pattern recognition?)
No worries for me. When Watson takes over, I will be off somewhere playing shuffleboard.
“It’s a particularly bad case. But, the question is why it appeared now, and why it’s getting worse.” She asked the patient about new hair products or family stress. The man said he’d just lost his job.
“Keep a diary,” she advised. “We can determine if there’s a link.”
Thus was my pedagogic legacy shattered in an instant. I’ve spent decades advising students not to tell patients they have a bad case of anything and never to ask them to keep diaries. Then, a foremost medical writer in a leading cultural journal endorses the reverse of both lessons. What was I thinking all these years?
I counseled students not to call any case “bad” because I saw how patients took it personally if I told them that. No matter how mild their diagnosis – rosacea and seborrhea, maladies less emperors than footmen– patients who heard theirs called “bad” looked sad, even insulted. Sad and insulted patients may give up and don’t follow treatment advice. (With such a bad case, why bother?) I didn’t urge patients to think that way. I just couldn’t ignore that they did. By contrast, assuring people that their case “wasn’t bad at all!” made them light up like Halloween pumpkins.
As for diaries, I’ve filed a few that patients handed me over the years. I showed these detailed chronicles to students to illustrate the lengths to which people will go to explain the unexplainable, like the ups and downs of idiopathic urticaria, eczema, and so forth:
- Thursday, August 6th, had sushi at a restaurant with friends.
- Sunday, September 3rd, watched science-fiction movie, unable to sleep that night.
- Monday, October 2nd, discarded fourth new detergent.
And so on.
In the meantime, several times each working day patients would troop in with randomly reoccurring conditions, atopic dermatitis above all, prompting dialogues like these:
“This is crazy! I never had anything like this before!”
“Well, actually, Ms. Jones, I treated you for the same thing in 2006.”
*********************
“This is bizarre! I never had this, and no one in my family ever did either.”
“I see. Well, here’s a prescription.”
“Come to think of it, my Mom had sensitive skin, and I get these dry patches on my arms and legs every winter.”
********************
“I’ve changed my soap three times and thrown out my makeup four times, and the rash keeps coming back. What should I do?”
“Stop throwing out your soap and makeup?”
And so on and on.
Sometimes, of course, semi-plausible causes seem to surface, such as stress. The question is, How useful is it to point this out? Consider the New Yorker case. Once the doctor “determined there is a link,” how might the conversation go?
“We have found the trigger, Mr. Smith. It’s stress.”
“Great! What should I do?”
“Don’t get laid off.”
No doctor (I hope) would ever say that, but patients present reports like the following all the time:
“As a kid, I was allergic to milk, but I’m not anymore.” (No, he wasn’t – he had infantile eczema that got blamed on milk.)
“Penicillin gave me hives.” (But, the hives lasted 6 weeks after the penicillin was stopped, which showed that the hives were idiopathic.)
“I’m very sensitive. I can’t use any moisturizer, any makeup, or all pills.” (People generate long litanies of sensitivities, piling one spurious correlation on another.)
Who benefits from “determining the link” when there isn’t any? Not the patients I’ve been seeing for forty years. Your patients? Maybe detergent manufacturers?
As to my errant pedagogy, with any luck, my students don’t remember a word I told them, a safe assumption for any teacher.
Either that or they don’t read the New Yorker.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
My face is all red!
My grandson is almost 3. He is, of course, very advanced in many areas, including self-awareness.
At the moment he is suffering from Fifth Disease. (See how advanced he is – he skipped right over Diseases One through Four!) Every now and then his face clouds over as he announces, to anyone and no one, “My face is all red!”
I am not worried about long-term psychic harm. A moment later his face lights up as he looks up at the sky. “It’s a helicopter!” he declares.
By the way, does his behavior remind you of anyone else you’ve met? How about all your patients with rosacea or facial keratosis pilaris who stop by the office to say, “My face is all red!” If they didn’t notice this themselves, others have been happy to help. “You’re all red!” say their family, friends, and coworkers. “Are you all right?”
What about patients like those? Would you call them vain, or cosmetically oriented?
It seems to me that the behavior of little kids – too young to elaborate their psychological musings – sheds light on the way their elders behave, or the way they will themselves when they grow up. Years ago, I was about to laser the face of a woman with an old pulsed-dye unit that left deep-purple bruises. Her job was to train monkeys for the blind. “I need makeup,” she said. “When my monkeys see red spots on my face, they get very upset and start to point at me.”
“Not just monkeys,” I replied.
To take another example, many years ago I saw a little tyke about 18 months old. His parents were concerned about a mole on his palm.
He was not happy to let me examine him, and he let me know. “It’s OK,” I said, in my most condescending, clueless adult voice. “Your Mom and Dad just asked me to check your boo-boo.”
That set him off. “No boo-boo!” he shouted. “No boo-boo!”
Well, silly me, I later realized. The tyke was right: Of course it was not a boo-boo. A boo-boo is an assault on the integrity of the body: a cut, a scrape, a burn, something new, painful, hard to look at. That is why 9.8 out of 10 people whom we freeze, burn, or puncture look the other way while we do it. It’s also why kids dial their screams down to whimpers when we hide what we froze, burned, or punctured by covering it with a Band-Aid. Now the boo-boo is out of sight.
The tyke’s mole, on the other hand, is not an insult to the body but a part of it. It’s him.
Fast forward 15 years and ask a teen with a large (but not giant) hairy congenital nevus if she wants it off. She does not. “That’s me,” she explains.
Or ask an adult with what you would think is a disfiguring facial port-wine stain what growing up with that was like. “It was fine,” they reply. “Strangers sometimes commented, but my friends knew that was just how I looked.”
Or listen to folks who want their liver spots lasered off. They point to a dozen or so, then add, “But don’t take off that one! That’s always been there. That’s just me.”
If you listen for it, you can pick up how early a lot of adult behavior starts. Little ones destined to be lifetime pickers start scraping off anything that’s raised above the skin. Teens finicky about facial moles or minute perturbations in their complexion grow into fussy adults.
We grownups learn to embroider our primal responses with words, thoughts, feeling, explanations. Kids just come out and say what they think – “My face is all red!”
Soon my grandson will have overcome his Fifth Disease without, I hope, graduating to any higher numbers. His other grandfather is a retired engineer who used to design helicopters. By next year I expect that our mutual grandson will be able to identify anything flying overhead by make and model number.
As I said, he’s very advanced.
Also cute as all get-out, (temporary) red face and all.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected]
My grandson is almost 3. He is, of course, very advanced in many areas, including self-awareness.
At the moment he is suffering from Fifth Disease. (See how advanced he is – he skipped right over Diseases One through Four!) Every now and then his face clouds over as he announces, to anyone and no one, “My face is all red!”
I am not worried about long-term psychic harm. A moment later his face lights up as he looks up at the sky. “It’s a helicopter!” he declares.
By the way, does his behavior remind you of anyone else you’ve met? How about all your patients with rosacea or facial keratosis pilaris who stop by the office to say, “My face is all red!” If they didn’t notice this themselves, others have been happy to help. “You’re all red!” say their family, friends, and coworkers. “Are you all right?”
What about patients like those? Would you call them vain, or cosmetically oriented?
It seems to me that the behavior of little kids – too young to elaborate their psychological musings – sheds light on the way their elders behave, or the way they will themselves when they grow up. Years ago, I was about to laser the face of a woman with an old pulsed-dye unit that left deep-purple bruises. Her job was to train monkeys for the blind. “I need makeup,” she said. “When my monkeys see red spots on my face, they get very upset and start to point at me.”
“Not just monkeys,” I replied.
To take another example, many years ago I saw a little tyke about 18 months old. His parents were concerned about a mole on his palm.
He was not happy to let me examine him, and he let me know. “It’s OK,” I said, in my most condescending, clueless adult voice. “Your Mom and Dad just asked me to check your boo-boo.”
That set him off. “No boo-boo!” he shouted. “No boo-boo!”
Well, silly me, I later realized. The tyke was right: Of course it was not a boo-boo. A boo-boo is an assault on the integrity of the body: a cut, a scrape, a burn, something new, painful, hard to look at. That is why 9.8 out of 10 people whom we freeze, burn, or puncture look the other way while we do it. It’s also why kids dial their screams down to whimpers when we hide what we froze, burned, or punctured by covering it with a Band-Aid. Now the boo-boo is out of sight.
The tyke’s mole, on the other hand, is not an insult to the body but a part of it. It’s him.
Fast forward 15 years and ask a teen with a large (but not giant) hairy congenital nevus if she wants it off. She does not. “That’s me,” she explains.
Or ask an adult with what you would think is a disfiguring facial port-wine stain what growing up with that was like. “It was fine,” they reply. “Strangers sometimes commented, but my friends knew that was just how I looked.”
Or listen to folks who want their liver spots lasered off. They point to a dozen or so, then add, “But don’t take off that one! That’s always been there. That’s just me.”
If you listen for it, you can pick up how early a lot of adult behavior starts. Little ones destined to be lifetime pickers start scraping off anything that’s raised above the skin. Teens finicky about facial moles or minute perturbations in their complexion grow into fussy adults.
We grownups learn to embroider our primal responses with words, thoughts, feeling, explanations. Kids just come out and say what they think – “My face is all red!”
Soon my grandson will have overcome his Fifth Disease without, I hope, graduating to any higher numbers. His other grandfather is a retired engineer who used to design helicopters. By next year I expect that our mutual grandson will be able to identify anything flying overhead by make and model number.
As I said, he’s very advanced.
Also cute as all get-out, (temporary) red face and all.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected]
My grandson is almost 3. He is, of course, very advanced in many areas, including self-awareness.
At the moment he is suffering from Fifth Disease. (See how advanced he is – he skipped right over Diseases One through Four!) Every now and then his face clouds over as he announces, to anyone and no one, “My face is all red!”
I am not worried about long-term psychic harm. A moment later his face lights up as he looks up at the sky. “It’s a helicopter!” he declares.
By the way, does his behavior remind you of anyone else you’ve met? How about all your patients with rosacea or facial keratosis pilaris who stop by the office to say, “My face is all red!” If they didn’t notice this themselves, others have been happy to help. “You’re all red!” say their family, friends, and coworkers. “Are you all right?”
What about patients like those? Would you call them vain, or cosmetically oriented?
It seems to me that the behavior of little kids – too young to elaborate their psychological musings – sheds light on the way their elders behave, or the way they will themselves when they grow up. Years ago, I was about to laser the face of a woman with an old pulsed-dye unit that left deep-purple bruises. Her job was to train monkeys for the blind. “I need makeup,” she said. “When my monkeys see red spots on my face, they get very upset and start to point at me.”
“Not just monkeys,” I replied.
To take another example, many years ago I saw a little tyke about 18 months old. His parents were concerned about a mole on his palm.
He was not happy to let me examine him, and he let me know. “It’s OK,” I said, in my most condescending, clueless adult voice. “Your Mom and Dad just asked me to check your boo-boo.”
That set him off. “No boo-boo!” he shouted. “No boo-boo!”
Well, silly me, I later realized. The tyke was right: Of course it was not a boo-boo. A boo-boo is an assault on the integrity of the body: a cut, a scrape, a burn, something new, painful, hard to look at. That is why 9.8 out of 10 people whom we freeze, burn, or puncture look the other way while we do it. It’s also why kids dial their screams down to whimpers when we hide what we froze, burned, or punctured by covering it with a Band-Aid. Now the boo-boo is out of sight.
The tyke’s mole, on the other hand, is not an insult to the body but a part of it. It’s him.
Fast forward 15 years and ask a teen with a large (but not giant) hairy congenital nevus if she wants it off. She does not. “That’s me,” she explains.
Or ask an adult with what you would think is a disfiguring facial port-wine stain what growing up with that was like. “It was fine,” they reply. “Strangers sometimes commented, but my friends knew that was just how I looked.”
Or listen to folks who want their liver spots lasered off. They point to a dozen or so, then add, “But don’t take off that one! That’s always been there. That’s just me.”
If you listen for it, you can pick up how early a lot of adult behavior starts. Little ones destined to be lifetime pickers start scraping off anything that’s raised above the skin. Teens finicky about facial moles or minute perturbations in their complexion grow into fussy adults.
We grownups learn to embroider our primal responses with words, thoughts, feeling, explanations. Kids just come out and say what they think – “My face is all red!”
Soon my grandson will have overcome his Fifth Disease without, I hope, graduating to any higher numbers. His other grandfather is a retired engineer who used to design helicopters. By next year I expect that our mutual grandson will be able to identify anything flying overhead by make and model number.
As I said, he’s very advanced.
Also cute as all get-out, (temporary) red face and all.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected]
Unforgiveness
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
Her visit seemed uneventful enough. Back for the semester break of her senior year, Jenna came in for acne follow-up.
She seemed to be doing pretty well: just a couple of active papules on each cheek, as well as some residual fading red marks from old lesions. Still, Jenna was not happy with her situation.
“Some of the marks you have just haven’t had time to fade away yet,” I said. “But since you’re still getting new ones, perhaps we should change antibiotics. After 4 months, it’s not likely that the one you’re taking will clear you up as fully as you want. Perhaps a different one will, although complete clearing can be a hard goal to reach.”
I discussed alternative choices with Jenna, settling on one as being most likely to help and unlikely to cause problems while she was away at school. I encouraged her to continue the same topical treatment she was on – she had had “reactions” to several previous topical tries – to contact me with any problems, and to return in May.
As I wrote up her prescriptions, I asked her about her academic major.
“Electrical engineering,” she said. “My goal is to work for a couple of years, then get advanced degrees in both engineering and law. I want to fuse both disciplines in a business context.”
I congratulated her on her clarity of vision. Few college seniors have more than a vague notion of where they’re headed. I wished her well and left the room.
Because the encounter seemed pleasant and innocuous, I was taken aback when my secretary came in a couple of hours later.
“Jenna’s father has called twice,” she said. “He says he’s furious that you didn’t spend enough time with his daughter or answer all of her questions.”
Sighing inwardly, I sat down during a break and called her.
“This is Dr. Rockoff,” I said. “I understand that you were unhappy with your visit.”
“That’s right,” she said, evenly. “Very unhappy. You only spent five minutes with me. I forgot to ask you all my questions.”
“I’m sorry,” I said. “What questions did you forget to ask me?”
“I have marks on my back where the acne used to be, and they haven’t gone away.”
“I see,” I said. “I thought we had covered that in connection with the marks still on your face, but I’m sorry if I didn’t make that clear. The marks need to fade on their own, and they will, though it will probably take a few more months.”
“You didn’t give me enough time at my previous visit,” she said. “I give people the benefit of the doubt, so I gave you a second chance, and again you kept me waiting, and then you didn’t spend enough time with me.”
“I’m very sorry that I didn’t meet your expectations,” I said. “If you come back to see me, I will try to do a better job. If you decide you want to get care elsewhere, of course I’ll be happy to forward your records to another physician.”
“I gave you a second chance,” Jenna said, “and again you failed to spend adequate time or deliver satisfactory service.”
“Again, my apologies,” I said. I wished her luck and ended the call.
After all these years, I think I’m pretty good at picking up physical and verbal cues of anger and dissatisfaction, but clearly I missed them all in Jenna’s case. Like everyone else, I’ve had my share of unhappy patients, but I’m hard put to remember being laid out in lavender with such gusto before.
When I finally hang up my spurs, there are a lot of things about practicing medicine that I will miss. Being dressed-down by unforgiving kids less than a third my age will not be one of them.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].
The dermatologic tourist
I’m not much of a traveler. I like to see the world through the adventures of my patients.
This is especially nice in the winter, such as during school vacation week. Within the past 24 hours, I’ve gotten messages from patients in Hawaii, Arizona, and Orlando.
Writing from Hawaii, Melvin showed me a photo of a small white spot that appeared on the outer aspect of his arm. I couldn’t make much of it except to tell him that it doesn’t look like anything that warrants a 9-hour flight to show it to me, at least not until he gets back to town.
Finally, Svetlana forwarded a photograph of a rash on her foot that she said had “just come yesterday.” This was the nicest case of cutaneous larva migrans that I’ve seen in quite some time, although I am fairly sure it has been there for more than a day. I tried not to sound too excited about her diagnosis, of course (“You’ve got the coolest parasite!”), and just suggested that she come in to see me on her return next week.
North, South, West. I’ve been all over, without leaving the chair facing my computer screen. (Nobody seems to have gotten a volcanic eruption in Iceland this year.) All this with no packing, no waiting in airports, no TSA lines. Who says traveling can’t be a pleasure?
Practice dermatology – see the world!
* * * * * * * * * * * * * * * * * * * * * * *
Brian was delighted. The fungal infection on his calf, treated for weeks with a topical steroid that had produced only intolerable itch, was subsiding nicely with oral terbinafine and topical ketoconazole.
“Can I drink when I take this medicine?” he asked. “The Internet says I shouldn’t.”
“It’s only another week, Brian,” I said. “Best to hold off ‘till then.”
“Because I really needed a drink last week,” he said.
“Why was that?”
“I was on a vacation with my father.”
“I see.”
“It was my father and his 70-year-old girlfriend.”
“Oh.”
“We were at a nudist colony.”
“You know, Brian,” I said. “Just hearing about that makes me want a drink myself.”
Practice can take you places you never went, places you’ll never get to, places you never want to get to.
* * * * * * * * * * * * * * * * * * * * * * *
Although I have patients fill out the usual consent form on oral isotretinoin, on which they promise to contact me if they become depressed, I rarely find anyone who does. Instead, people tend to become rather happy once their acne improves.
Since I’m not a psychiatrist, I try to do an amateur job of assessing mood when patients come in for their monthly follow-up. I pass on my technique for any of you might find it useful.
“Hello, Peter, are you having any problems?”
“No.”
“Do you get headaches?”
“No.”
“Nosebleeds?”
“No.”
“Any aches and pains in your muscles?”
“No.”
“Are you depressed?”
“No.”
“Are you always this negative?”
If the patient smiles while saying, “No,” you’re in good shape. If not, consider suggesting a therapist.
Better still, send the patient to the Caribbean. Then propose that you go come along yourself as a consultant, just to keep an eye on things.
And bring sunscreen. For the two of you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
I’m not much of a traveler. I like to see the world through the adventures of my patients.
This is especially nice in the winter, such as during school vacation week. Within the past 24 hours, I’ve gotten messages from patients in Hawaii, Arizona, and Orlando.
Writing from Hawaii, Melvin showed me a photo of a small white spot that appeared on the outer aspect of his arm. I couldn’t make much of it except to tell him that it doesn’t look like anything that warrants a 9-hour flight to show it to me, at least not until he gets back to town.
Finally, Svetlana forwarded a photograph of a rash on her foot that she said had “just come yesterday.” This was the nicest case of cutaneous larva migrans that I’ve seen in quite some time, although I am fairly sure it has been there for more than a day. I tried not to sound too excited about her diagnosis, of course (“You’ve got the coolest parasite!”), and just suggested that she come in to see me on her return next week.
North, South, West. I’ve been all over, without leaving the chair facing my computer screen. (Nobody seems to have gotten a volcanic eruption in Iceland this year.) All this with no packing, no waiting in airports, no TSA lines. Who says traveling can’t be a pleasure?
Practice dermatology – see the world!
* * * * * * * * * * * * * * * * * * * * * * *
Brian was delighted. The fungal infection on his calf, treated for weeks with a topical steroid that had produced only intolerable itch, was subsiding nicely with oral terbinafine and topical ketoconazole.
“Can I drink when I take this medicine?” he asked. “The Internet says I shouldn’t.”
“It’s only another week, Brian,” I said. “Best to hold off ‘till then.”
“Because I really needed a drink last week,” he said.
“Why was that?”
“I was on a vacation with my father.”
“I see.”
“It was my father and his 70-year-old girlfriend.”
“Oh.”
“We were at a nudist colony.”
“You know, Brian,” I said. “Just hearing about that makes me want a drink myself.”
Practice can take you places you never went, places you’ll never get to, places you never want to get to.
* * * * * * * * * * * * * * * * * * * * * * *
Although I have patients fill out the usual consent form on oral isotretinoin, on which they promise to contact me if they become depressed, I rarely find anyone who does. Instead, people tend to become rather happy once their acne improves.
Since I’m not a psychiatrist, I try to do an amateur job of assessing mood when patients come in for their monthly follow-up. I pass on my technique for any of you might find it useful.
“Hello, Peter, are you having any problems?”
“No.”
“Do you get headaches?”
“No.”
“Nosebleeds?”
“No.”
“Any aches and pains in your muscles?”
“No.”
“Are you depressed?”
“No.”
“Are you always this negative?”
If the patient smiles while saying, “No,” you’re in good shape. If not, consider suggesting a therapist.
Better still, send the patient to the Caribbean. Then propose that you go come along yourself as a consultant, just to keep an eye on things.
And bring sunscreen. For the two of you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
I’m not much of a traveler. I like to see the world through the adventures of my patients.
This is especially nice in the winter, such as during school vacation week. Within the past 24 hours, I’ve gotten messages from patients in Hawaii, Arizona, and Orlando.
Writing from Hawaii, Melvin showed me a photo of a small white spot that appeared on the outer aspect of his arm. I couldn’t make much of it except to tell him that it doesn’t look like anything that warrants a 9-hour flight to show it to me, at least not until he gets back to town.
Finally, Svetlana forwarded a photograph of a rash on her foot that she said had “just come yesterday.” This was the nicest case of cutaneous larva migrans that I’ve seen in quite some time, although I am fairly sure it has been there for more than a day. I tried not to sound too excited about her diagnosis, of course (“You’ve got the coolest parasite!”), and just suggested that she come in to see me on her return next week.
North, South, West. I’ve been all over, without leaving the chair facing my computer screen. (Nobody seems to have gotten a volcanic eruption in Iceland this year.) All this with no packing, no waiting in airports, no TSA lines. Who says traveling can’t be a pleasure?
Practice dermatology – see the world!
* * * * * * * * * * * * * * * * * * * * * * *
Brian was delighted. The fungal infection on his calf, treated for weeks with a topical steroid that had produced only intolerable itch, was subsiding nicely with oral terbinafine and topical ketoconazole.
“Can I drink when I take this medicine?” he asked. “The Internet says I shouldn’t.”
“It’s only another week, Brian,” I said. “Best to hold off ‘till then.”
“Because I really needed a drink last week,” he said.
“Why was that?”
“I was on a vacation with my father.”
“I see.”
“It was my father and his 70-year-old girlfriend.”
“Oh.”
“We were at a nudist colony.”
“You know, Brian,” I said. “Just hearing about that makes me want a drink myself.”
Practice can take you places you never went, places you’ll never get to, places you never want to get to.
* * * * * * * * * * * * * * * * * * * * * * *
Although I have patients fill out the usual consent form on oral isotretinoin, on which they promise to contact me if they become depressed, I rarely find anyone who does. Instead, people tend to become rather happy once their acne improves.
Since I’m not a psychiatrist, I try to do an amateur job of assessing mood when patients come in for their monthly follow-up. I pass on my technique for any of you might find it useful.
“Hello, Peter, are you having any problems?”
“No.”
“Do you get headaches?”
“No.”
“Nosebleeds?”
“No.”
“Any aches and pains in your muscles?”
“No.”
“Are you depressed?”
“No.”
“Are you always this negative?”
If the patient smiles while saying, “No,” you’re in good shape. If not, consider suggesting a therapist.
Better still, send the patient to the Caribbean. Then propose that you go come along yourself as a consultant, just to keep an eye on things.
And bring sunscreen. For the two of you.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His new book “Act Like a Doctor, Think Like a Patient” is now available at amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].