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When the iPad is on the other foot
Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.
“How do you spell that again?” he wanted to know.
I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.
“Wait, you say it isn’t fungal?”
“No ...”
Typing. “And you don’t know the cause?”
“No, the medical term for that is ‘idiopathic’ ...”
“Wait, how do you spell that?”
I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”
More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”
“A cream. Betamethasone dipropionate.”
“Hold on! How do you spell that?”
I spelled it out, along with “augmented” and “0.05%.”
The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)
When my student and I left the room, I took him aside.
“Did you see anything unusual about how that visit went?” I asked.
When he looked blank, I explained: “The patient didn’t look me in the eye once.”
Yes, come to think of it, the student had noticed that.
“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.
“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.
“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.
“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”
He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.
No need to spell this out for the younger generation, literally or otherwise.
Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:
Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:
“The patient is a flight attendant for Diflucan Airlines.”
Check them out. Their restrooms are so clean you can go barefoot.
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].
Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.
“How do you spell that again?” he wanted to know.
I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.
“Wait, you say it isn’t fungal?”
“No ...”
Typing. “And you don’t know the cause?”
“No, the medical term for that is ‘idiopathic’ ...”
“Wait, how do you spell that?”
I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”
More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”
“A cream. Betamethasone dipropionate.”
“Hold on! How do you spell that?”
I spelled it out, along with “augmented” and “0.05%.”
The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)
When my student and I left the room, I took him aside.
“Did you see anything unusual about how that visit went?” I asked.
When he looked blank, I explained: “The patient didn’t look me in the eye once.”
Yes, come to think of it, the student had noticed that.
“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.
“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.
“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.
“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”
He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.
No need to spell this out for the younger generation, literally or otherwise.
Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:
Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:
“The patient is a flight attendant for Diflucan Airlines.”
Check them out. Their restrooms are so clean you can go barefoot.
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].
Sometimes patients take a few notes when I talk, but Niles was different. As I started to spout words of wisdom about his granuloma annulare, he whipped out a tablet and started to type.
“How do you spell that again?” he wanted to know.
I spelled it out, and Niles tapped away. I launched into my usual explanation – how the cause is unknown, how it is roundish but not a fungus, how it usually has no systemic significance, and so on. At each point, looking down at the keyboard, he stopped me.
“Wait, you say it isn’t fungal?”
“No ...”
Typing. “And you don’t know the cause?”
“No, the medical term for that is ‘idiopathic’ ...”
“Wait, how do you spell that?”
I regretted using the word. “I-D-I-O-P-A-T-H-I-C.”
More typing. “Wait, hold on. OK, got it. And what did you say you want to treat it with?”
“A cream. Betamethasone dipropionate.”
“Hold on! How do you spell that?”
I spelled it out, along with “augmented” and “0.05%.”
The interview continued a bit longer. As we concluded, Niles thanked me for seeing him. At no time did he raise his eyes from the tablet, even as he was putting it back into its case. He acted the same way my staff does when I walk into the lunchroom. There I see three or four people sitting around a table with a sandwich or salad in front of them, staring at their smartphones. The same way groups of people do nowadays, everywhere. (A couple of years ago, I took some of my grandchildren out on a rowboat on the Charles River on a sunny summer afternoon. There we saw two young women, oars across their laps, examining their phones.)
When my student and I left the room, I took him aside.
“Did you see anything unusual about how that visit went?” I asked.
When he looked blank, I explained: “The patient didn’t look me in the eye once.”
Yes, come to think of it, the student had noticed that.
“Not very satisfying, was it?” I asked. “It’s hard to talk to somebody who isn’t looking at you. It’s even a little insulting, don’t you think?” He agreed.
“When you’re out in practice in a few years,” I said, “the person in the exam room looking at the computer and not making eye contact is likely to be you. Think about how it felt to watch me talking at the top of the patient’s head, and then imagine how your patients are likely to feel when they’re talking to the top of your head. Unless of course your laptop has a screen that blocks your head altogether.
“I just bring a clipboard with sheets of paper on it into the exam room,” I said. “The way things are working out, I think I’ll be able to make it to the end of my career without being forced to use an electronic device.
“You have your whole career ahead of you, though,” I told him. “I guess you’ll figure out how to make communication work.”
He will too, no doubt. He’ll have to. As the Romans used to say, times change, and we change with them.
No need to spell this out for the younger generation, literally or otherwise.
Just a short addendum from the world of artificial intelligence, as applied to voice recognition software:
Last week I saw Chad, who had seen my colleague a year earlier and come back for a skin check. She had described Chad’s occupation:
“The patient is a flight attendant for Diflucan Airlines.”
Check them out. Their restrooms are so clean you can go barefoot.
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].
But you told me...
“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”
I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.
In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.
No, I didn’t.
I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?
That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.
Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.
Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”
Nope, not even close.
What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?
The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.
“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”
Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.
No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”
Philip nods. I think he understands. But I thought so last time too, didn’t I?
I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”
No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.
Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.
I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.
I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”
That was clear. I think.
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].
“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”
I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.
In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.
No, I didn’t.
I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?
That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.
Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.
Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”
Nope, not even close.
What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?
The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.
“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”
Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.
No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”
Philip nods. I think he understands. But I thought so last time too, didn’t I?
I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”
No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.
Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.
I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.
I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”
That was clear. I think.
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].
“The other doctor I went to told me that the spot he biopsied on my nose was a skin cancer,” Larry said. “But he told me just to keep an eye on it.”
I always try not to roll my eyes when a patient quotes another doctor, especially if the quote doesn’t make much sense. In the first place, it’s bad form to act like you’re smarter than somebody else. In the second place, you probably aren’t.
In the third place, what the patient says the doctor said may not be what the doctor actually said. I have many chances to learn this firsthand, such as when patients quote me incorrectly to myself.
No, I didn’t.
I point out to students that, to patients, calling a mole benign is always provisional. They’re happy that it’s benign today. Tomorrow, who knows?
That’s why when I reassure people about moles I’m not worried about, I say, “It’s benign... and it will always be benign.” When they look startled – as they often do – I elaborate: “Because if I thought it could turn into skin cancer, I would have to remove it right now.” Then they nod, somewhat tentatively. What I just said clearly made sense, only it contradicts what they always assumed was true, which is that you should always keep an eye on things.
Since I thought Steve’s mole was benign, I did not tell him that we need to keep an eye on it, any more than Larry’s previous doctor had told him just to keep an eye on a biopsy-proved skin cancer. Steve just thought that’s what I must have said, because that’s what makes sense to him.
Then there was Amanda, who had stopped her acne gel weeks before. “It was making me worse,” she explained, “and you told me to stop the medicine if anything happened.”
Nope, not even close.
What I did say – what I always say – was this: “These are the reactions you might experience. If you think you’re getting them or any others, call me right away, so I can consider changing to something different.” I never tell patients to just stop treatment and not tell anyone. Who would?
The opposite happens too. Just as some people stop medication without telling their doctors, others find it just as hard to stop treatment even when they’re instructed to.
“When your seborrhea quiets down,” I say, “you can stop the cream. Resume it when you need to, but stop again as soon as you clear up.”
Easy for me to say. But in walks Phillip. He’s been using applying desonide daily for 6 years. “You said I should keep using it,” he explains.
No, I didn’t. “What I was trying to say,” I politely explain, “is that when your skin feels fine, it’s OK to stop. They you can use it again when the rash comes back. Keeping up applying the cream doesn’t stop the rash from coming back if it’s going to.”
Philip nods. I think he understands. But I thought so last time too, didn’t I?
I should also give a shout-out to the patients who say, “I’ve been using the clotrimazole-betamethasone cream you prescribed...”
No, I did not prescribe clotrimazole-betamethasone! I would lose my membership in the dermatologists’ union.
Researchers who study cross-cultural practice look into issues of miscommunication between providers and consumers who come from distant cultures, where basic notions get in the way of each party’s understanding the other. No one seems that interested in studying all the miscommunication that goes on between educated native-English speakers, in medical offices no less than in the halls of the legislature.
I got hold of Larry’s biopsy report, by the way. It was read out as “actinic keratosis,” which is why Larry’s former doctor had told him that they would just watch it.
I called Larry. “It was not an actual cancer,” I told him. “Just precancerous. Come back in 6 months. We’ll keep an eye on it.”
That was clear. I think.
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].
It’s working! (No it’s not! Yes it is!)
A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
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] .
A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
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] .
A man walks into a doctor’s office, snapping his fingers.
“Why are you snapping your fingers?” asks the doctor.
“To keep the elephants away,” says the man, still snapping his fingers.
“That’s ridiculous!” says the doctor. “There are no elephants within 3,000 miles of here!”
“You see,” says the man, still snapping. “It’s working!”
Even saying that sounds strange. Don’t we physicians apply the evidence-based fruits of science? What does the patient’s mind have to do with that?
Yesterday we saw Emma, who spent 5 years in Austria. On her back was perfectly circular purpura.
“Who does your cupping?” I asked her.
“My acupuncturist,” said Emma. “He does cupping too.”
“What’s it for?”
“Aches and pains, stress, that sort of thing.”
“Does it help?”
“It seems to,” said Emma. Sometimes, anyway.”
Later I asked my student what she thought Emma meant. “What did Emma see or feel to make her conclude that cupping was working, at least sometimes? Did she feel better Tuesday than Monday? What if she felt worse again Wednesday? Would that mean the treatment wasn’t working anymore? That it works some days and not others?”
If you think this line of analysis applies only to exotic forms of alternative medicine, consider how often we could ask the same questions about the medically approved treatments we prescribe every day.
Acne
• Henrietta, for whom I’d prescribed clindamycin in the morning and tretinoin at night. Her verdict? “I stopped the clindamycin because it didn’t work. But I love the tretinoin—it works great!”
Since she was putting both creams on exactly the same area, what did Henrietta observe to lead her to this paradoxical conclusion?
• Janet has two pimples, yet she’s decided that minocycline doesn’t work. Her evidence? “I still get breakouts around my period.”
Eczema
• “Amcinonide worked amazingly but clobetasol didn’t work at all!”
• “I stopped the betamethasone. Calendula works better.”
• And of course: “Sure the cream helped, but the rash came back!”
Patients say things like this all day long. From a medical standpoint, active ingredients work better than inert vehicles. In theory, class 1 steroids are more effective than class 3 steroids.
Perhaps, but many of my patients don’t agree. Maybe their eczema has gone into remission, in which case anything will work. Even if so, there is no way I can prove that to them. So I usually don’t try.
Psoriasis
“Your psoriasis looks better.”
“No, it’s worse.”
“Why? It covers a lot less skin than it used to.”
“But now it’s coming in new places.”
One could go on. With my students, I often do. If they learn nothing else, I try to convey the essential difference between a person and a toaster. Which is this:
If you know how to fix a toaster, the toaster does not have to agree with you.
A person is another matter. Patients have minds to go with their parts. They pick up knowledge from places doctors have never been and make inferences doctors would never make. Then they act on this knowledge and those inferences by saying things like: “The morning cream didn’t work but the night cream did, so I stopped the morning cream.”
I therefore advise students to ask patients two questions first thing:
• What treatments are the patients actually using? Assuming that they are doing what the chart says you asked them to do can jam your foot so deep in your mouth that you’ll never get it out.
• How do the patients themselves think they’re doing? One man with a couple of pimples or scaly spots is thrilled. Another with the same pimples or spots is miserable. It’s helpful to find out which he is before making suggestions. (See foot in mouth, above.)
Emma, by the way, was unhappy that she couldn’t find a practitioner of craniosacral therapy (look it up) as proficient as the one she had in Austria.
I asked her how she judged proficiency but won’t bother you with her answer. I just referred her to a physician who practices both Eastern and Western medicine.
That worked for her.
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] .
The $400 generic
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
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].
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
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].
Oren is 11. I often see him around the neighborhood.
The other day I gave his father a lift. “Oren had a rash on his face,” said Ben, slipping into the passenger seat. “The pediatrician said she thought it was eczema, but she gave him an acne medicine.”
I raised my eyebrows, but said nothing.
“How much did it cost?” I asked.
“$400.”
“$400!” I couldn’t quite stifle my shock. “What was in the cream?” I asked.
“Here it is,” he said. “I took a picture of the tube on my phone.”
He showed me a snapshot of a tube of clindamycin/benzoyl peroxide.
Although I try not to meddle in the medical issues of friends, I decided to make a small exception in this case. “Next time someone prescribes an expensive skin cream,” I said, “let me know. Maybe I can help you find a more affordable alternative.”
What skin problem did Oren have? I have no idea. I see his face enough to know that he has no acne at all. Nor would acne go away in 2 days.
On the other hand, if he did have a flare of eczema – I’ve never noticed that on him either – acne medicine would aggravate it, if anything.
Besides those questions, I have another one: Regardless of what she thought the diagnosis was, why on earth did Oren’s pediatrician feel compelled to prescribe a $400 generic? I say “compelled” because she told Ben straight out that the cream was going to cost a lot. But she just had to prescribe it because her experience told her it worked.
What experience did she have, exactly? What else had she tried that didn’t work? And what did she mean by “work”?
Ben’s and Oren’s experience is just a small, unnoticed incident of no general interest. It will spur no magazine exposés, incite no lawsuits, launch no professional or political inquiries.
• Oren’s pediatrician will go on prescribing a hideously priced cream intended to treat who-knows-what. Nobody will suggest to her that she might at least consider doing otherwise.
• Pharmacy benefit managers will not crack down on either pediatrician or cream. They have bigger fish to fry, like biologics that cost $50K per year.
• Health care administrators will take no notice. They will instead think up more creative and onerous disincentives to restrain providers from prescribing anything expensive. Whether they will also figure out how to keep monopolistic generic drug manufacturers from jacking up prices into the stratosphere is something else.
• Medical educators will strengthen their focus on sophisticated science (Genomics! Precision Medicine!), while doing a wholly inadequate job of passing on simple lessons that might help primary clinicians do a better job of managing everyday skin problems. Just yesterday, my colleague and I saw two patients who had been taking doxycycline for years with no clinical benefit, three kids with eczema who had used a succession of antifungal creams for over 4 months, one woman who had been dousing herself repeatedly with permethrin – to no avail – because her mites lived exclusively in her brain and those of her prescribers, and a partridge with alopecia in a pear tree. (OK, not the last one). All that in just 1 day!
• Simple common sense will stay elusive. Most rashes are really not rocket science.
I apologize, dear colleagues, for being so cranky. Much jollier to be upbeat and amusing. It’s just that, after 40 years in the business, observing the same skull-exploding clinical behaviors gets a little old, along with the observer.
Oren and Ben are fine, though. Oren’s face is as clear as ever. (It’s genetic – his mom has great skin). Even Ben isn’t disturbed. First of all, the rash went away. Second, he has an annual $2,000 drug cost deductible, “so I’d have to spend it anyway.”
“Look, Ben,” I told him, “if you need help exhausting your deductible, I’ll be happy to send you a couple of bills. No problem.”
He smiled. I guess he doesn’t really need my help on that.
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].
A dermatologic little list
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
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].
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
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].
The following was presented to the Pennsylvania Academy of Dermatology at its annual meeting in Bedford Springs, Pa. The verses were sung to the tune of “I’ve Got a Little List” from Gilbert and Sullivan’s “Mikado.”
For those unsure of how the words fit, the editors of this periodical are considering a lottery. Winners will get an MP3 of the author singing the lyrics. Losers will get two copies.
I’ve Got a Little (Dermatologic) List
One day your staff informs you that a patient who’s called up
Has asked that you call back –
At once! Call him right back! –
But to your consternation you discover that you lack
The telephonic knack
You lack the call-back knack
For the man who wants to be assured he knows that he’s been called
And so he’s ordered voice mail – but it hasn’t been installed
Or else you hear a message that suffuses you with gloom –
Her voice mail works just dandy, but it’s full and got no room
Or else he’s a millennial who doesn’t use the phone
What right has he to moan?
We’ll just leave him alone!
Among the many irritants providing me with grist
The naive integumentalist
Must be there on my list
The one who’s sure that any scaly rash that comes among us
Is certainly a fungus
What else? A yeast or fungus!
Yet doles out betamethasone for every scaly sole
And smears all roundish eczema with ketoconazole
And knows they can’t be bedbugs if the bites don’t come in three
And rules out pityriasis because there is no tree!
And calls each itch that patients have inscribed into a furrow
A scabietic burrow –
An idiocy thorough!
Returning now to patients, I really must insist
To put some on my list
(In fact, they top the list!)
They’re the people who have generated their own laundry list
Or else at least the gist –
(Their list contains the gist) –
The redness of my pimples now takes much too long to fade
I have a strange sensation just below my shoulder blade
I get these funny white bumps when my family travels south
And intermittent cracking at the corners of my mouth
I have a newish brown mark on the right side of my nose
And frequent scaling in between my first and second toes
Now let me double check my list, because you see I fear
That I’ll leave something crucial out – now that I’ve got you here!
This armpit mark’s irregular – you see, there is a stipple
And new light yellow bumps have just appeared around my nipple
The red splotch underneath my breast – my doctor says it’s yeast
I have this dark spot. See my navel? Go one inch northeast
Oh, wait, there is a skin tag on the right side of my neck
And now, as long as I am here, let’s do a body check ...
And yes, there is just one more thing I must ask you about
I am concerned – in fact I’m sure – my hair is falling out!
Now that we are concluding, we should surely not forget
The ones not on the list
Forget about the list!
Those patients every one of us is very glad we’ve met
And happy to assist
The ones who would be missed
Those lovely people each of us is gratified to serve
Who often praise our efforts rather more than we deserve
And anyhow the tables turn, and so sooner or later
We docs will take our turn as patients, crunched to bits of data ...
I hope my cranky litany has served to entertain ya
So thank you for inviting me –
Good morning, Pennsylvania!
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].
Miscellany
Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:
Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”
Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...
You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”
“Where do you buy an analyst couch?” I asked.
“Analyticcouch.com,” she explained. “Available in a variety of colors.”
What a country!
No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”
The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.
“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”
That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.
“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”
There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.
Then the other day Marcy surprised me with this:
“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”
A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...
You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.
My jaw dropped, but no words came out.
“It’s that sign you put up,” he said, “right on the exam room door.”
As I don’t usually read my own signs, I turned to look. The sign read:
“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”
“It says, ‘No-Showed,” I said. Not ‘No Showers.”
I resisted the urge to refer him to an optometrist.
This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”
“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”
“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.
“Upstairs,” I said. “Seventh floor.”
Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”
“But it has to be a whole day ...”
“Fifteen hours,” he said. “I’ll give you 15 hours.”
“But we need ...”
“Eighteen hours. OK?”
“Well, not really. You see, the test has to be a whole day ...”
“All right, 21 hours. That’s my best offer.”
Maybe if I could get him to spend the day in that Egyptian bathroom ...
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 on amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:
Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”
Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...
You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”
“Where do you buy an analyst couch?” I asked.
“Analyticcouch.com,” she explained. “Available in a variety of colors.”
What a country!
No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”
The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.
“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”
That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.
“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”
There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.
Then the other day Marcy surprised me with this:
“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”
A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...
You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.
My jaw dropped, but no words came out.
“It’s that sign you put up,” he said, “right on the exam room door.”
As I don’t usually read my own signs, I turned to look. The sign read:
“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”
“It says, ‘No-Showed,” I said. Not ‘No Showers.”
I resisted the urge to refer him to an optometrist.
This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”
“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”
“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.
“Upstairs,” I said. “Seventh floor.”
Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”
“But it has to be a whole day ...”
“Fifteen hours,” he said. “I’ll give you 15 hours.”
“But we need ...”
“Eighteen hours. OK?”
“Well, not really. You see, the test has to be a whole day ...”
“All right, 21 hours. That’s my best offer.”
Maybe if I could get him to spend the day in that Egyptian bathroom ...
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 on amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
Many interesting things happen in a medical office, most of which don’t merit a full column. Here are some from my own past few months:
Endocrine Knee? I was hard put to explain the calluses on both my patient’s knees. As I tried to formulate a question, he rescued me by saying, “I’m an endocrinologist. I spend a lot of my time on my knees, trimming the toenails of elderly diabetics.”
Who knew? At least bending the knee to insurers and regulators doesn’t require keratolytics ...
You can get anything online. My patient was about to graduate with a degree in psychoanalysis. “I have to set up my office,” she said, “drapes, analyst couch, and so forth.”
“Where do you buy an analyst couch?” I asked.
“Analyticcouch.com,” she explained. “Available in a variety of colors.”
What a country!
No I’m not, Officer! Many patients consider removing facial red spots that make them self-conscious, but Harriet’s reason was unique. “I got pulled over by a cop for an illegal change of lanes,” she said. “When he saw the red spot under my eye, he assumed I was a drunk. ‘Get over there, punk,’ he said.”
The other bathroom is upstairs. Stan listed his occupation as “muralist.” Picturing him sneaking up to blank walls on street corners in the middle of the night with a can of Benjamin Moore to ply his trade, I asked where he draws his murals.
“Most of my work is residential,” he said. “For instance, last year I did a bathroom in Framingham. The motif they wanted was ancient Egypt. I had to do a lot of research on the 18th dynasty, to get the details exactly right.”
That made sense. You wouldn’t want a dangling hieroglyphic participle in your downstairs lavatory. I asked him how it worked out.
“The client was delighted,” he said, “only there was one problem. Whenever guests came over for a dinner party, there was always a long line, because whoever was in the bathroom wouldn’t come out.”
There are always alternatives. By now I am used to hearing patients extol the virtues of exotic treatments: Vicks VapoRub for toenail tinea, tea tree oil for most anything. Apple cider vinegar for everything else.
Then the other day Marcy surprised me with this:
“I stopped the minocycline,” she said, “Instead I started using celery, which I ground up and boiled and then froze and then applied to the face.”
A little bit of a production, perhaps – grinding, boiling, freezing. As long as it works ...
You need a different kind of doctor. “I see I won’t be able to shower for 3 days,” said the new patient.
My jaw dropped, but no words came out.
“It’s that sign you put up,” he said, “right on the exam room door.”
As I don’t usually read my own signs, I turned to look. The sign read:
“If you have no-showed without notice three times, we reserve the right to reschedule you at our convenience.”
“It says, ‘No-Showed,” I said. Not ‘No Showers.”
I resisted the urge to refer him to an optometrist.
This reminded me of another episode some time ago, when a patient listed his Chief Complaint as, “I want Lasik Surgery.”
“Forgive me,” I said, “but why would you ask a dermatologist for Lasik surgery?”
“Doesn’t the sign on your door say, “Boston Ophthalmology?” he asked.
“Upstairs,” I said. “Seventh floor.”
Negotiating with Father Time. We suspected porphyria, and ordered a 24-hour urine collection. “I’m a busy executive,” said the patient. “I haven’t got time to collect it for that long.”
“But it has to be a whole day ...”
“Fifteen hours,” he said. “I’ll give you 15 hours.”
“But we need ...”
“Eighteen hours. OK?”
“Well, not really. You see, the test has to be a whole day ...”
“All right, 21 hours. That’s my best offer.”
Maybe if I could get him to spend the day in that Egyptian bathroom ...
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 on amazon.com and barnesandnoble.com. This is his second book. Write to him at [email protected].
Loss of autonomy
At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”
Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.
A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”
“Academics used to be autonomous,” he said. “No more.”
Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”
New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?
Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.
“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”
“What will you do instead?” I asked him.
“Something with dogs,” he said.
And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.
An internist told me how things are in her new dispensation.
“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.
“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”
Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.
Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.
To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.
Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.
To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.
At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”
Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.
A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”
“Academics used to be autonomous,” he said. “No more.”
Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”
New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?
Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.
“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”
“What will you do instead?” I asked him.
“Something with dogs,” he said.
And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.
An internist told me how things are in her new dispensation.
“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.
“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”
Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.
Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.
To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.
Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.
To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.
At the summer meetings of the American Academy of Dermatology, AAD President Abel Torres screened a video of members responding to the question, “What keeps you up at night?” A recurring refrain in many of their responses was, “loss of autonomy.”
Many physicians feel they are losing autonomy. No doubt they are right. But physicians are not alone in their loss.
A young academic friend of mine had a similar lament. “Some assistant dean sent me an email ordering me to grade my students in a way that made no sense,” he said. “I challenged him to explain why. He answered that my school was following the guidelines of some organization I’d never heard of.”
“Academics used to be autonomous,” he said. “No more.”
Another professor friend decided to retire. “Forty years in the department,” he said, “10 as chair. Now a junior administrator tells me that I have to spend more hours on campus, even though I don’t have anything useful to do when I’m there. She said there are new rules for more academic efficiency.”
New administrators. Guidelines. Efficiency. Experienced hands dropping out or retiring out of frustration. Any of these sound familiar?
Teachers also complain to me about their loss of autonomy. “I used to be able to use judgment,” said one. “I knew what worked for a specific student. Now I just teach to the standardized test.
“For every one of my 23 kindergartners, I spent 1 hour filling out an iPad questionnaire on reading readiness. I’ve had it.”
“What will you do instead?” I asked him.
“Something with dogs,” he said.
And so it goes. Accountants and attorneys complain about heavy reporting regulations, with new ones added each year. Judges in Wisconsin make sentencing decisions using proprietary algorithms that no one outside the company that sells the algorithms has validated. Financial advisers have clients sign boilerplate statements documenting that they accept a certain level of risk. These clients may or may not understand what “level of risk” really implies, but either way they must sign a form, and the form must be filed. If you didn’t document it, you didn’t do it. If you documented it, you did it, even though you may not have really done anything meaningful.
An internist told me how things are in her new dispensation.
“They allow 15 minutes for a physical,” she said, “which is not enough anyway. But I also have to check off boxes for the EMR that add nothing to patient care. Last year we had to start asking about gender status. ‘What was your gender assignment at birth?’ ‘What is it now?’ We have to ask that every year – and click the box that says we did it.
“Several docs in our group retired. Another bunch went concierge. They couldn’t deal with it anymore.”
Metrics. Algorithms. Higher authorities who tell professionals what to do, how to do it, how to record it, business quants with scant understanding of what professionals actually profess. All so familiar and tiresome. It’s everywhere, and it’s bigger than any of us.
Loss of autonomy by professionals across the board reflects a changed understanding by society at large of what quality service is and how it should be judged. Numbers are in. Personal judgment – in our case, clinical judgment – is out. Since judgment can’t be measured, it cannot be trusted.
To a certain extent, autonomy is an illusion. We can do what we want as long as powers larger than we are – natural, social, political – let us do it. Those powers may lie dormant for a while, but they’re always there, and always have been. When they wake up and change the rules of the game, everyone has to adapt. New burdens in the practice of medicine are just one instance of a much broader trend.
Our professional organizations know this well. They are hard at work giving the authorities, government, and insurance administrators what they demand: data showing that what we do is useful, in the quantitative terms the authorities will accept.
To the extent that they succeed, we will be able to do some of what we want to do. Young people entering the medical field will expect nothing more. Some of their older colleagues will be satisfied that they are autonomous enough. The rest will have to find something else to do.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.
Turning down treatment
How do you treat a patient who doesn’t want to be treated?
It depends. If the problem is acne or a wart, then it’s all right to let it go.
Harriet, however, has HIV. And a facial basal cell carcinoma.
Now what?
Perhaps it still depends.
After showing me a red spot on her right cheek, Harriet put me on notice right away. “I don’t believe in unnecessary treatments,” she said.
I asked her what she meant.
“I’ve been HIV positive since the mid-1980s,” she said. “Last year, my doctor wanted to pump me full of those poisons. So I changed doctors.”
“What does your new doctor think?” I asked.
“My T-cell counts aren’t very good. He also thinks I should take those medicines, but I don’t see him much.
“I went to another dermatologist about a different problem. He got very angry at me, because I had called in advance to ask not to be seen by a resident. They told me that would be OK, but the resident showed up anyway. When the doctor also came in and I tried to explain, he threw me out of the clinic.”
By now, I’d gotten the picture: Harriet has her own ideas about things and is not about to take advice with which she doesn’t agree. What makes Harriet different is not that she ignores medical advice – people do that all the time – but that she comes right out and says so to the doctor’s face. Others wait till they get home.
So what do you do when a patient shows that he or she is ready to look you in the eye and turn you down flat?
One response is to leave the room in a huff. After all, who’s the expert here, and who’s trying to help whom?
That reaction is understandable, but if the doctor walks out, who is being helped? The patient, or the doctor?
There is, of course, another approach, which is to suppress professional ego considerations and ask:
1. What are the actual medical stakes? What is the worst that could happen if the patient refuses treatment?
2. What realistic options, if any, are there to change the patient’s mind?
3. Why is the patient behaving that way, anyway?
In Harriet’s case, what are the medical stakes? I am no HIV specialist, but how many patients who seroconverted in the 1980s are still around to consider their options? (Other such patients have told me their doctors really don’t understand how patients like them survived.) If Harriet is sexually inactive and does not try to donate blood, how sure are we that she isn’t better off doing nothing?
Besides, what other options are there to change her mind?
Before turning to my third question, I have to plan what to do if – when – the biopsy confirms my clinical diagnosis of basal cell. I will inform Harriet, and recommend Mohs surgery. Suppose she refuses and wants a lesser procedure, or no surgery at all. What next?
This happens. If the patient is elderly, and the lesion is not near a strategic organ, such as the eye, it may be acceptable just to watch the lesion. Some basal cells grow fast, others barely grow at all. If Harriet decides to do nothing, I could explain my preference – surgery – and her risks – lesion growth and bigger surgery later – and insist on seeing her every 2 months.
Which brings us to our third question: Why would Harriet act this way?
Two possibilities occur to me. The first is fear. Scared people often act aggressively. Calmed down, they relent.
The second is that Harriet is what the English call bloody minded; in other words, deliberately uncooperative.
Battling with the bloody minded is not helpful for anybody.
Negotiating with difficult people is much less gratifying than giving advice and being respectfully thanked for our efforts and expertise.
Sometimes, though, the best we can do is to swallow our professional pride, try to defuse what fear we can, and show that we will push only as hard as clinical risk truly justifies. This is not always easy to do but is often worth the effort. It may certainly be the best available alternative.
Harriet’s biopsy showed a basal cell. She readily agreed to surgery.
You never know.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].
How do you treat a patient who doesn’t want to be treated?
It depends. If the problem is acne or a wart, then it’s all right to let it go.
Harriet, however, has HIV. And a facial basal cell carcinoma.
Now what?
Perhaps it still depends.
After showing me a red spot on her right cheek, Harriet put me on notice right away. “I don’t believe in unnecessary treatments,” she said.
I asked her what she meant.
“I’ve been HIV positive since the mid-1980s,” she said. “Last year, my doctor wanted to pump me full of those poisons. So I changed doctors.”
“What does your new doctor think?” I asked.
“My T-cell counts aren’t very good. He also thinks I should take those medicines, but I don’t see him much.
“I went to another dermatologist about a different problem. He got very angry at me, because I had called in advance to ask not to be seen by a resident. They told me that would be OK, but the resident showed up anyway. When the doctor also came in and I tried to explain, he threw me out of the clinic.”
By now, I’d gotten the picture: Harriet has her own ideas about things and is not about to take advice with which she doesn’t agree. What makes Harriet different is not that she ignores medical advice – people do that all the time – but that she comes right out and says so to the doctor’s face. Others wait till they get home.
So what do you do when a patient shows that he or she is ready to look you in the eye and turn you down flat?
One response is to leave the room in a huff. After all, who’s the expert here, and who’s trying to help whom?
That reaction is understandable, but if the doctor walks out, who is being helped? The patient, or the doctor?
There is, of course, another approach, which is to suppress professional ego considerations and ask:
1. What are the actual medical stakes? What is the worst that could happen if the patient refuses treatment?
2. What realistic options, if any, are there to change the patient’s mind?
3. Why is the patient behaving that way, anyway?
In Harriet’s case, what are the medical stakes? I am no HIV specialist, but how many patients who seroconverted in the 1980s are still around to consider their options? (Other such patients have told me their doctors really don’t understand how patients like them survived.) If Harriet is sexually inactive and does not try to donate blood, how sure are we that she isn’t better off doing nothing?
Besides, what other options are there to change her mind?
Before turning to my third question, I have to plan what to do if – when – the biopsy confirms my clinical diagnosis of basal cell. I will inform Harriet, and recommend Mohs surgery. Suppose she refuses and wants a lesser procedure, or no surgery at all. What next?
This happens. If the patient is elderly, and the lesion is not near a strategic organ, such as the eye, it may be acceptable just to watch the lesion. Some basal cells grow fast, others barely grow at all. If Harriet decides to do nothing, I could explain my preference – surgery – and her risks – lesion growth and bigger surgery later – and insist on seeing her every 2 months.
Which brings us to our third question: Why would Harriet act this way?
Two possibilities occur to me. The first is fear. Scared people often act aggressively. Calmed down, they relent.
The second is that Harriet is what the English call bloody minded; in other words, deliberately uncooperative.
Battling with the bloody minded is not helpful for anybody.
Negotiating with difficult people is much less gratifying than giving advice and being respectfully thanked for our efforts and expertise.
Sometimes, though, the best we can do is to swallow our professional pride, try to defuse what fear we can, and show that we will push only as hard as clinical risk truly justifies. This is not always easy to do but is often worth the effort. It may certainly be the best available alternative.
Harriet’s biopsy showed a basal cell. She readily agreed to surgery.
You never know.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].
How do you treat a patient who doesn’t want to be treated?
It depends. If the problem is acne or a wart, then it’s all right to let it go.
Harriet, however, has HIV. And a facial basal cell carcinoma.
Now what?
Perhaps it still depends.
After showing me a red spot on her right cheek, Harriet put me on notice right away. “I don’t believe in unnecessary treatments,” she said.
I asked her what she meant.
“I’ve been HIV positive since the mid-1980s,” she said. “Last year, my doctor wanted to pump me full of those poisons. So I changed doctors.”
“What does your new doctor think?” I asked.
“My T-cell counts aren’t very good. He also thinks I should take those medicines, but I don’t see him much.
“I went to another dermatologist about a different problem. He got very angry at me, because I had called in advance to ask not to be seen by a resident. They told me that would be OK, but the resident showed up anyway. When the doctor also came in and I tried to explain, he threw me out of the clinic.”
By now, I’d gotten the picture: Harriet has her own ideas about things and is not about to take advice with which she doesn’t agree. What makes Harriet different is not that she ignores medical advice – people do that all the time – but that she comes right out and says so to the doctor’s face. Others wait till they get home.
So what do you do when a patient shows that he or she is ready to look you in the eye and turn you down flat?
One response is to leave the room in a huff. After all, who’s the expert here, and who’s trying to help whom?
That reaction is understandable, but if the doctor walks out, who is being helped? The patient, or the doctor?
There is, of course, another approach, which is to suppress professional ego considerations and ask:
1. What are the actual medical stakes? What is the worst that could happen if the patient refuses treatment?
2. What realistic options, if any, are there to change the patient’s mind?
3. Why is the patient behaving that way, anyway?
In Harriet’s case, what are the medical stakes? I am no HIV specialist, but how many patients who seroconverted in the 1980s are still around to consider their options? (Other such patients have told me their doctors really don’t understand how patients like them survived.) If Harriet is sexually inactive and does not try to donate blood, how sure are we that she isn’t better off doing nothing?
Besides, what other options are there to change her mind?
Before turning to my third question, I have to plan what to do if – when – the biopsy confirms my clinical diagnosis of basal cell. I will inform Harriet, and recommend Mohs surgery. Suppose she refuses and wants a lesser procedure, or no surgery at all. What next?
This happens. If the patient is elderly, and the lesion is not near a strategic organ, such as the eye, it may be acceptable just to watch the lesion. Some basal cells grow fast, others barely grow at all. If Harriet decides to do nothing, I could explain my preference – surgery – and her risks – lesion growth and bigger surgery later – and insist on seeing her every 2 months.
Which brings us to our third question: Why would Harriet act this way?
Two possibilities occur to me. The first is fear. Scared people often act aggressively. Calmed down, they relent.
The second is that Harriet is what the English call bloody minded; in other words, deliberately uncooperative.
Battling with the bloody minded is not helpful for anybody.
Negotiating with difficult people is much less gratifying than giving advice and being respectfully thanked for our efforts and expertise.
Sometimes, though, the best we can do is to swallow our professional pride, try to defuse what fear we can, and show that we will push only as hard as clinical risk truly justifies. This is not always easy to do but is often worth the effort. It may certainly be the best available alternative.
Harriet’s biopsy showed a basal cell. She readily agreed to surgery.
You never know.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].
Reactions to reactions
When patients say they had “a reaction” to some treatment, they often don’t mean what we would call allergy or even intolerance. This doesn’t make their reluctance – or refusal – to consider what we suggest any less insistent.
I’ve lost track, for insistence, of the number of patients who called 2 days after I prescribed clindamycin lotion to complain that it “dried me out completely.”
When a customer in a cosmetic store or pharmacy returns a skin care cream because of that kind of “reaction,” the store takes it back, no questions asked. This is not just good business practice; in that context, both the customer and the salesperson use the word “reaction” the way laymen do, not the way doctors do.
If you doubt a reaction is real and say so, however gently, the response you may get is, “That may be true, Doctor, but my body is sensitive. I get strange reactions.”
Like most everyone else in practice, I use negotiating tactics, such as: “Stop the cream for 3 days, then try it again, but just in one spot in front of your left ear.”
Some patients agree to try this. Mostly, nothing happens, they resume the medication, and life goes on. For fearful people, we have to use something else. Sometimes patients and I run through a succession of options, each of which produces an inscrutable “reaction.”
As the years pass, I’ve gotten better at gauging the range of true reactions to medications. At the same time, the list of perplexing things patients complain about gets longer all the time. Lately, there’s been a run of them:
• The woman who used low-strength tretinoin cream all of twice and stopped 2 weeks ago who insisted that “my face is still all dried out.” I assured her that 2 days of tretinoin cannot damage the skin forever, but she remains unconvinced.
• The man who says that putting tretinoin on his face “made me dry out all over.”
• The mother who said her daughter stopped my steroid cream because “every time we used it, her tongue broke out in blisters.”
• The middle-aged woman who claimed, “I can’t take minocycline because it changed the color of my teeth and my eyes.”
• The young woman who puts clindamycin pads only on her right cheek, where she still has pimples, but not on the left, “because it makes the pimples go away on the cheek that has them, but on the other side it makes pimples come out.”
When I hear complaints like these, I just sigh and make a lateral move.
But sometimes I run out of lateral moves. The other month a woman told me that doxycycline made her “tired.” We tried minocycline, but that made her “irritable.” “My body is prone to strange reactions that no one else gets,” she explained. Then she asked for a third option.
“I honestly don’t know what to suggest,” I apologized. “Because your body reacts in ways that other people don’t, I can’t predict what some other treatment will do to you, even if it hasn’t done it to anyone else.”
She asked for her records, to get another opinion. I happily complied.
Speaking of weird “reactions,” there are of course the ones listed on e-scribing programs. Here are a couple:
• Hydrocortisone valerate has been associated with WARTS. (Capitalized)
• Hydrocortisone valerate has been associated with tinea cruris.
Make any sense to you? Me neither.
I end with a call I got the other day from a pharmacist. This concerned a patient for whom I had prescribed oral doxycycline and topical tretinoin. The message was, “Please call regarding drug interaction.”
When I got through, I politely asked the nature of this interaction. The pharmacist said she didn’t know exactly, but would look into it and fax me the details.
Half an hour later I got a sheet explaining the there is an increased risk of pseudotumor cerebri when patients take both oral tretinoin and oral tetracyclines.
That is correct: Not isotretinoin. Oral tretinoin. Used any oral tretinoin lately?
At any rate, the helpful pharmacist wrote at the bottom, “This interaction is flagged by several insurers for topical tretinoin too.”
Thank heavens for computer-generated warnings. Whatever would we do without them?
Besides, it’s nice to know that even after all these years, I can still react myself, with surprise.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].
When patients say they had “a reaction” to some treatment, they often don’t mean what we would call allergy or even intolerance. This doesn’t make their reluctance – or refusal – to consider what we suggest any less insistent.
I’ve lost track, for insistence, of the number of patients who called 2 days after I prescribed clindamycin lotion to complain that it “dried me out completely.”
When a customer in a cosmetic store or pharmacy returns a skin care cream because of that kind of “reaction,” the store takes it back, no questions asked. This is not just good business practice; in that context, both the customer and the salesperson use the word “reaction” the way laymen do, not the way doctors do.
If you doubt a reaction is real and say so, however gently, the response you may get is, “That may be true, Doctor, but my body is sensitive. I get strange reactions.”
Like most everyone else in practice, I use negotiating tactics, such as: “Stop the cream for 3 days, then try it again, but just in one spot in front of your left ear.”
Some patients agree to try this. Mostly, nothing happens, they resume the medication, and life goes on. For fearful people, we have to use something else. Sometimes patients and I run through a succession of options, each of which produces an inscrutable “reaction.”
As the years pass, I’ve gotten better at gauging the range of true reactions to medications. At the same time, the list of perplexing things patients complain about gets longer all the time. Lately, there’s been a run of them:
• The woman who used low-strength tretinoin cream all of twice and stopped 2 weeks ago who insisted that “my face is still all dried out.” I assured her that 2 days of tretinoin cannot damage the skin forever, but she remains unconvinced.
• The man who says that putting tretinoin on his face “made me dry out all over.”
• The mother who said her daughter stopped my steroid cream because “every time we used it, her tongue broke out in blisters.”
• The middle-aged woman who claimed, “I can’t take minocycline because it changed the color of my teeth and my eyes.”
• The young woman who puts clindamycin pads only on her right cheek, where she still has pimples, but not on the left, “because it makes the pimples go away on the cheek that has them, but on the other side it makes pimples come out.”
When I hear complaints like these, I just sigh and make a lateral move.
But sometimes I run out of lateral moves. The other month a woman told me that doxycycline made her “tired.” We tried minocycline, but that made her “irritable.” “My body is prone to strange reactions that no one else gets,” she explained. Then she asked for a third option.
“I honestly don’t know what to suggest,” I apologized. “Because your body reacts in ways that other people don’t, I can’t predict what some other treatment will do to you, even if it hasn’t done it to anyone else.”
She asked for her records, to get another opinion. I happily complied.
Speaking of weird “reactions,” there are of course the ones listed on e-scribing programs. Here are a couple:
• Hydrocortisone valerate has been associated with WARTS. (Capitalized)
• Hydrocortisone valerate has been associated with tinea cruris.
Make any sense to you? Me neither.
I end with a call I got the other day from a pharmacist. This concerned a patient for whom I had prescribed oral doxycycline and topical tretinoin. The message was, “Please call regarding drug interaction.”
When I got through, I politely asked the nature of this interaction. The pharmacist said she didn’t know exactly, but would look into it and fax me the details.
Half an hour later I got a sheet explaining the there is an increased risk of pseudotumor cerebri when patients take both oral tretinoin and oral tetracyclines.
That is correct: Not isotretinoin. Oral tretinoin. Used any oral tretinoin lately?
At any rate, the helpful pharmacist wrote at the bottom, “This interaction is flagged by several insurers for topical tretinoin too.”
Thank heavens for computer-generated warnings. Whatever would we do without them?
Besides, it’s nice to know that even after all these years, I can still react myself, with surprise.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].
When patients say they had “a reaction” to some treatment, they often don’t mean what we would call allergy or even intolerance. This doesn’t make their reluctance – or refusal – to consider what we suggest any less insistent.
I’ve lost track, for insistence, of the number of patients who called 2 days after I prescribed clindamycin lotion to complain that it “dried me out completely.”
When a customer in a cosmetic store or pharmacy returns a skin care cream because of that kind of “reaction,” the store takes it back, no questions asked. This is not just good business practice; in that context, both the customer and the salesperson use the word “reaction” the way laymen do, not the way doctors do.
If you doubt a reaction is real and say so, however gently, the response you may get is, “That may be true, Doctor, but my body is sensitive. I get strange reactions.”
Like most everyone else in practice, I use negotiating tactics, such as: “Stop the cream for 3 days, then try it again, but just in one spot in front of your left ear.”
Some patients agree to try this. Mostly, nothing happens, they resume the medication, and life goes on. For fearful people, we have to use something else. Sometimes patients and I run through a succession of options, each of which produces an inscrutable “reaction.”
As the years pass, I’ve gotten better at gauging the range of true reactions to medications. At the same time, the list of perplexing things patients complain about gets longer all the time. Lately, there’s been a run of them:
• The woman who used low-strength tretinoin cream all of twice and stopped 2 weeks ago who insisted that “my face is still all dried out.” I assured her that 2 days of tretinoin cannot damage the skin forever, but she remains unconvinced.
• The man who says that putting tretinoin on his face “made me dry out all over.”
• The mother who said her daughter stopped my steroid cream because “every time we used it, her tongue broke out in blisters.”
• The middle-aged woman who claimed, “I can’t take minocycline because it changed the color of my teeth and my eyes.”
• The young woman who puts clindamycin pads only on her right cheek, where she still has pimples, but not on the left, “because it makes the pimples go away on the cheek that has them, but on the other side it makes pimples come out.”
When I hear complaints like these, I just sigh and make a lateral move.
But sometimes I run out of lateral moves. The other month a woman told me that doxycycline made her “tired.” We tried minocycline, but that made her “irritable.” “My body is prone to strange reactions that no one else gets,” she explained. Then she asked for a third option.
“I honestly don’t know what to suggest,” I apologized. “Because your body reacts in ways that other people don’t, I can’t predict what some other treatment will do to you, even if it hasn’t done it to anyone else.”
She asked for her records, to get another opinion. I happily complied.
Speaking of weird “reactions,” there are of course the ones listed on e-scribing programs. Here are a couple:
• Hydrocortisone valerate has been associated with WARTS. (Capitalized)
• Hydrocortisone valerate has been associated with tinea cruris.
Make any sense to you? Me neither.
I end with a call I got the other day from a pharmacist. This concerned a patient for whom I had prescribed oral doxycycline and topical tretinoin. The message was, “Please call regarding drug interaction.”
When I got through, I politely asked the nature of this interaction. The pharmacist said she didn’t know exactly, but would look into it and fax me the details.
Half an hour later I got a sheet explaining the there is an increased risk of pseudotumor cerebri when patients take both oral tretinoin and oral tetracyclines.
That is correct: Not isotretinoin. Oral tretinoin. Used any oral tretinoin lately?
At any rate, the helpful pharmacist wrote at the bottom, “This interaction is flagged by several insurers for topical tretinoin too.”
Thank heavens for computer-generated warnings. Whatever would we do without them?
Besides, it’s nice to know that even after all these years, I can still react myself, with surprise.
Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Dermatology News since January 2002. Write to him at [email protected].
Groundhog Day
Early in my career, an attorney asked me to review a malpractice case. “The question,” he said, “is whether liquid nitrogen is the standard of care for treating warts.”
Come again?
A young woman had visited an academic center, where a physician froze her warts. These blistered and turned purple. Alarmed, she went to an ER, where doctors admitted her for cellulitis and gave her intravenous antibiotics for several days.
I later submitted an essay based on this case to my malpractice insurer’s Risk Management Contest, in which I called for better communication between treating doctors and those who follow up. I placed second and got a check from my malpractice insurer. How cool is that?
I hadn’t thought about that case in years, until last month. Earvin is a late-middle-aged gent with psoriasis on his elbows and liver spots on his chest. He asked me to freeze them, as I had done before.
After lunch 2 days later, my secretary buzzed me. “The man on the phone is very unhappy,” she said. “He says he called this morning and no one called back. He says if he doesn’t hear from you, his next call will be to his attorney.”
I phoned Earvin. My apology for not having gotten the message before was met with frigid hostility. “That’s unconscionable,” he said.
“My skin swelled up like a balloon,” he told me. “I know what to expect with freezing, and this never happened before. I think this time you froze me with a heavy hand. When I didn’t hear from you, I went to an urgent care clinic down the street. They said it was infected and prescribed an antibiotic ointment. I had to wait an hour, and the ointment cost $49.”
I held my breath. “Actually,” I said, “I don’t think it’s infected.”
“They said it was infected,” said Earvin. “It is swollen. I’m afraid it is going to scar. The cream cost $49.”
Straining to keep my voice even, I replied, “Would you like me to have a look at it?”
“I live too far,” he said. “I don’t have a ride. Maybe I will come tomorrow if someone can take me.”
Later that day I called him back. “I live the next town over from you,” I said. “I will stop by on my way home.” He agreed, and told me the color of his house.
Earvin let me in looking less angry than fearful. One glance at his chest told me what I needed to know: There was no infection. His skin looked like what skin looks like after it’s been frozen. Other treated areas – the ones Earvin wasn’t worried about – looked the same to me, though clearly not to him. “This one was worse,” he said. “It’s gone down since this morning.”
After examining Earvin with my cell phone flashlight, I sat down across from him. “Let me be clear,” I said. “You are not infected. Some areas frozen at the same time in the same way blister more briskly than others. In the end they heal fine, and so will yours. You’re not going to scar.”
Earvin relaxed a little. “I was afraid I’d done something I didn’t need to. My mother had skin cancer on her chest, not far from where this one is. My skin was discolored and swollen. The doctor at urgent care said it was infected.” There was a pause, as Earvin slumped in his chair. “I feel better,” he allowed.
There it was, the whole package – thinking that was full of hopelessly muddled categories. Infection? Scarring? Skin cancer? Yes to all? And there was moral anxiety – disappointment in himself for doing something needless and now having to pay the price – as well as anger at me as the instrument of retribution. Who knows what else? There were so many strands, hopelessly coiled, impossible to disentangle.
And all wrapped up in elemental terror. What have I done? What has he done?
Earvin did not need treatment. He needed a hug. Metaphorically, that is what I gave him.
So much angst, so much anger, so much fear, so little time. To be frank, it gets tiring.
People like to quote the philosopher George Santayana. He said that those who cannot remember the past are condemned to repeat it.
I like to paraphrase the even greater philosopher Bill Murray of “Groundhog Day”: Those who do remember the past are condemned to repeat it anyway.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Early in my career, an attorney asked me to review a malpractice case. “The question,” he said, “is whether liquid nitrogen is the standard of care for treating warts.”
Come again?
A young woman had visited an academic center, where a physician froze her warts. These blistered and turned purple. Alarmed, she went to an ER, where doctors admitted her for cellulitis and gave her intravenous antibiotics for several days.
I later submitted an essay based on this case to my malpractice insurer’s Risk Management Contest, in which I called for better communication between treating doctors and those who follow up. I placed second and got a check from my malpractice insurer. How cool is that?
I hadn’t thought about that case in years, until last month. Earvin is a late-middle-aged gent with psoriasis on his elbows and liver spots on his chest. He asked me to freeze them, as I had done before.
After lunch 2 days later, my secretary buzzed me. “The man on the phone is very unhappy,” she said. “He says he called this morning and no one called back. He says if he doesn’t hear from you, his next call will be to his attorney.”
I phoned Earvin. My apology for not having gotten the message before was met with frigid hostility. “That’s unconscionable,” he said.
“My skin swelled up like a balloon,” he told me. “I know what to expect with freezing, and this never happened before. I think this time you froze me with a heavy hand. When I didn’t hear from you, I went to an urgent care clinic down the street. They said it was infected and prescribed an antibiotic ointment. I had to wait an hour, and the ointment cost $49.”
I held my breath. “Actually,” I said, “I don’t think it’s infected.”
“They said it was infected,” said Earvin. “It is swollen. I’m afraid it is going to scar. The cream cost $49.”
Straining to keep my voice even, I replied, “Would you like me to have a look at it?”
“I live too far,” he said. “I don’t have a ride. Maybe I will come tomorrow if someone can take me.”
Later that day I called him back. “I live the next town over from you,” I said. “I will stop by on my way home.” He agreed, and told me the color of his house.
Earvin let me in looking less angry than fearful. One glance at his chest told me what I needed to know: There was no infection. His skin looked like what skin looks like after it’s been frozen. Other treated areas – the ones Earvin wasn’t worried about – looked the same to me, though clearly not to him. “This one was worse,” he said. “It’s gone down since this morning.”
After examining Earvin with my cell phone flashlight, I sat down across from him. “Let me be clear,” I said. “You are not infected. Some areas frozen at the same time in the same way blister more briskly than others. In the end they heal fine, and so will yours. You’re not going to scar.”
Earvin relaxed a little. “I was afraid I’d done something I didn’t need to. My mother had skin cancer on her chest, not far from where this one is. My skin was discolored and swollen. The doctor at urgent care said it was infected.” There was a pause, as Earvin slumped in his chair. “I feel better,” he allowed.
There it was, the whole package – thinking that was full of hopelessly muddled categories. Infection? Scarring? Skin cancer? Yes to all? And there was moral anxiety – disappointment in himself for doing something needless and now having to pay the price – as well as anger at me as the instrument of retribution. Who knows what else? There were so many strands, hopelessly coiled, impossible to disentangle.
And all wrapped up in elemental terror. What have I done? What has he done?
Earvin did not need treatment. He needed a hug. Metaphorically, that is what I gave him.
So much angst, so much anger, so much fear, so little time. To be frank, it gets tiring.
People like to quote the philosopher George Santayana. He said that those who cannot remember the past are condemned to repeat it.
I like to paraphrase the even greater philosopher Bill Murray of “Groundhog Day”: Those who do remember the past are condemned to repeat it anyway.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
Early in my career, an attorney asked me to review a malpractice case. “The question,” he said, “is whether liquid nitrogen is the standard of care for treating warts.”
Come again?
A young woman had visited an academic center, where a physician froze her warts. These blistered and turned purple. Alarmed, she went to an ER, where doctors admitted her for cellulitis and gave her intravenous antibiotics for several days.
I later submitted an essay based on this case to my malpractice insurer’s Risk Management Contest, in which I called for better communication between treating doctors and those who follow up. I placed second and got a check from my malpractice insurer. How cool is that?
I hadn’t thought about that case in years, until last month. Earvin is a late-middle-aged gent with psoriasis on his elbows and liver spots on his chest. He asked me to freeze them, as I had done before.
After lunch 2 days later, my secretary buzzed me. “The man on the phone is very unhappy,” she said. “He says he called this morning and no one called back. He says if he doesn’t hear from you, his next call will be to his attorney.”
I phoned Earvin. My apology for not having gotten the message before was met with frigid hostility. “That’s unconscionable,” he said.
“My skin swelled up like a balloon,” he told me. “I know what to expect with freezing, and this never happened before. I think this time you froze me with a heavy hand. When I didn’t hear from you, I went to an urgent care clinic down the street. They said it was infected and prescribed an antibiotic ointment. I had to wait an hour, and the ointment cost $49.”
I held my breath. “Actually,” I said, “I don’t think it’s infected.”
“They said it was infected,” said Earvin. “It is swollen. I’m afraid it is going to scar. The cream cost $49.”
Straining to keep my voice even, I replied, “Would you like me to have a look at it?”
“I live too far,” he said. “I don’t have a ride. Maybe I will come tomorrow if someone can take me.”
Later that day I called him back. “I live the next town over from you,” I said. “I will stop by on my way home.” He agreed, and told me the color of his house.
Earvin let me in looking less angry than fearful. One glance at his chest told me what I needed to know: There was no infection. His skin looked like what skin looks like after it’s been frozen. Other treated areas – the ones Earvin wasn’t worried about – looked the same to me, though clearly not to him. “This one was worse,” he said. “It’s gone down since this morning.”
After examining Earvin with my cell phone flashlight, I sat down across from him. “Let me be clear,” I said. “You are not infected. Some areas frozen at the same time in the same way blister more briskly than others. In the end they heal fine, and so will yours. You’re not going to scar.”
Earvin relaxed a little. “I was afraid I’d done something I didn’t need to. My mother had skin cancer on her chest, not far from where this one is. My skin was discolored and swollen. The doctor at urgent care said it was infected.” There was a pause, as Earvin slumped in his chair. “I feel better,” he allowed.
There it was, the whole package – thinking that was full of hopelessly muddled categories. Infection? Scarring? Skin cancer? Yes to all? And there was moral anxiety – disappointment in himself for doing something needless and now having to pay the price – as well as anger at me as the instrument of retribution. Who knows what else? There were so many strands, hopelessly coiled, impossible to disentangle.
And all wrapped up in elemental terror. What have I done? What has he done?
Earvin did not need treatment. He needed a hug. Metaphorically, that is what I gave him.
So much angst, so much anger, so much fear, so little time. To be frank, it gets tiring.
People like to quote the philosopher George Santayana. He said that those who cannot remember the past are condemned to repeat it.
I like to paraphrase the even greater philosopher Bill Murray of “Groundhog Day”: Those who do remember the past are condemned to repeat it anyway.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.
