Alan Rockoff, MD

They put Bill’s chart on my desk, with a cover sheet. “I authorize you to send all my medical records,” it read, over his signature. The destination was a dermatologist across town.

I reviewed Bill’s record. His last visit was 6 months ago, just a skin check to mop up some solar keratoses. One of many such visits over 20 years. A basal cell on the shoulder 10 years ago. Nothing eventful.

“What happened?” I wondered, as I signed off on sending his chart. Had I missed a skin cancer?

That thought brought to mind Maxine. She, too, had been my patient for many years. Her niece still comes in.

Maxine had a history of sun damage, along with a few low-grade skin cancers. One day I biopsied a hand lesion. It was a squamous cell. I called her with the results and referred her to a surgeon. Nothing new or special, or so it seemed.

A few weeks later I got Maxine’s letter. “Send all my medical records.”

So I had not missed her squamous cell, but she still wanted out. How come?

Over the course of a clinical career, patients drop out. They move away, pass away, change insurance, retire to Florida or Arizona. Sometimes they come back, years later. They lost their job in L.A., or moved back to nurse a sick parent. Perhaps they got their old insurance back, or their new doctor stopped accepting the kind they had. It’s been 5 years, 10 years. You didn’t even notice they were gone.

The same thing happens of course in other aspects of life. People move in and out of our orbit: school chums, work mates, parents of kids who play with our kids, neighbors. They grow up, move away, get lost somehow. Unless they reappear, we often don’t realize they aren’t there anymore.

Most of the time there was no special event, no angry falling out. Lives just diverged. We lost whatever we had in common. Nothing personal.

But former acquaintances don’t generally send you a note officially severing relations, a letter notifying you to, “Forget about me. You won’t be seeing me again.”

If we got such a letter, we might actually be relieved. Chances are, though, that if we weren’t expecting it (or secretly wishing for it), we would wonder what it was about. Was there a quarrel we didn’t even know about?

Chances are we wouldn’t try too hard to find out what the problem was, though. Whatever we did manage to learn would probably be unpleasant and unfixable.

The same is true when patients ask us to send all their records. Most people stay, unless something propels them to move on. Absent a shift in geography or health insurance, whatever did overcome their inertia it is probably not something we want to know.

“This will happen to you,” I tell my students. “Count on it. Patients will ask for their records. They may send you a note of complaint. ‘You didn’t find the skin cancer on mother’s leg,’ they may say. Or else, ‘Your treatments were useless. I went to another doctor who actually knew what was wrong and gave me what I needed.’ ” Nowadays, people put such sentiments into unfavorable online reviews.

“When you get letters or read reviews like those,” I advise, “count to 10 before you respond. Then count to 10 again. Then don’t respond. I’ve tried doing it the other way and regretted it every time.

“Mostly, there’s no potential litigation involved,” I continue. “If there is a threatened suit, you’ll need an attorney to respond anyway. Otherwise, learn what you can from the patient’s disappointment, file the letter, note the review, send all the records, and move on.”

We doctors tend to be an ingratiating sort. Because we try to help people, we want them to like us. Many will, often to excess. But good as we ever get, try as hard as we can, not everybody will like us. That’s life, in and out of medical practice.

Rejection is never pleasant. Experience thickens the skin, but even then a signed request to “Send all my records” can sting. Even after all these years, it still does.

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.

They put Bill’s chart on my desk, with a cover sheet. “I authorize you to send all my medical records,” it read, over his signature. The destination was a dermatologist across town.

I reviewed Bill’s record. His last visit was 6 months ago, just a skin check to mop up some solar keratoses. One of many such visits over 20 years. A basal cell on the shoulder 10 years ago. Nothing eventful.

“What happened?” I wondered, as I signed off on sending his chart. Had I missed a skin cancer?

That thought brought to mind Maxine. She, too, had been my patient for many years. Her niece still comes in.

Maxine had a history of sun damage, along with a few low-grade skin cancers. One day I biopsied a hand lesion. It was a squamous cell. I called her with the results and referred her to a surgeon. Nothing new or special, or so it seemed.

A few weeks later I got Maxine’s letter. “Send all my medical records.”

So I had not missed her squamous cell, but she still wanted out. How come?

Over the course of a clinical career, patients drop out. They move away, pass away, change insurance, retire to Florida or Arizona. Sometimes they come back, years later. They lost their job in L.A., or moved back to nurse a sick parent. Perhaps they got their old insurance back, or their new doctor stopped accepting the kind they had. It’s been 5 years, 10 years. You didn’t even notice they were gone.

The same thing happens of course in other aspects of life. People move in and out of our orbit: school chums, work mates, parents of kids who play with our kids, neighbors. They grow up, move away, get lost somehow. Unless they reappear, we often don’t realize they aren’t there anymore.

Most of the time there was no special event, no angry falling out. Lives just diverged. We lost whatever we had in common. Nothing personal.

But former acquaintances don’t generally send you a note officially severing relations, a letter notifying you to, “Forget about me. You won’t be seeing me again.”

If we got such a letter, we might actually be relieved. Chances are, though, that if we weren’t expecting it (or secretly wishing for it), we would wonder what it was about. Was there a quarrel we didn’t even know about?

Chances are we wouldn’t try too hard to find out what the problem was, though. Whatever we did manage to learn would probably be unpleasant and unfixable.

The same is true when patients ask us to send all their records. Most people stay, unless something propels them to move on. Absent a shift in geography or health insurance, whatever did overcome their inertia it is probably not something we want to know.

“This will happen to you,” I tell my students. “Count on it. Patients will ask for their records. They may send you a note of complaint. ‘You didn’t find the skin cancer on mother’s leg,’ they may say. Or else, ‘Your treatments were useless. I went to another doctor who actually knew what was wrong and gave me what I needed.’ ” Nowadays, people put such sentiments into unfavorable online reviews.

“When you get letters or read reviews like those,” I advise, “count to 10 before you respond. Then count to 10 again. Then don’t respond. I’ve tried doing it the other way and regretted it every time.

“Mostly, there’s no potential litigation involved,” I continue. “If there is a threatened suit, you’ll need an attorney to respond anyway. Otherwise, learn what you can from the patient’s disappointment, file the letter, note the review, send all the records, and move on.”

We doctors tend to be an ingratiating sort. Because we try to help people, we want them to like us. Many will, often to excess. But good as we ever get, try as hard as we can, not everybody will like us. That’s life, in and out of medical practice.

Rejection is never pleasant. Experience thickens the skin, but even then a signed request to “Send all my records” can sting. Even after all these years, it still does.

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.

They put Bill’s chart on my desk, with a cover sheet. “I authorize you to send all my medical records,” it read, over his signature. The destination was a dermatologist across town.

I reviewed Bill’s record. His last visit was 6 months ago, just a skin check to mop up some solar keratoses. One of many such visits over 20 years. A basal cell on the shoulder 10 years ago. Nothing eventful.

“What happened?” I wondered, as I signed off on sending his chart. Had I missed a skin cancer?

That thought brought to mind Maxine. She, too, had been my patient for many years. Her niece still comes in.

Maxine had a history of sun damage, along with a few low-grade skin cancers. One day I biopsied a hand lesion. It was a squamous cell. I called her with the results and referred her to a surgeon. Nothing new or special, or so it seemed.

A few weeks later I got Maxine’s letter. “Send all my medical records.”

So I had not missed her squamous cell, but she still wanted out. How come?

Over the course of a clinical career, patients drop out. They move away, pass away, change insurance, retire to Florida or Arizona. Sometimes they come back, years later. They lost their job in L.A., or moved back to nurse a sick parent. Perhaps they got their old insurance back, or their new doctor stopped accepting the kind they had. It’s been 5 years, 10 years. You didn’t even notice they were gone.

The same thing happens of course in other aspects of life. People move in and out of our orbit: school chums, work mates, parents of kids who play with our kids, neighbors. They grow up, move away, get lost somehow. Unless they reappear, we often don’t realize they aren’t there anymore.

Most of the time there was no special event, no angry falling out. Lives just diverged. We lost whatever we had in common. Nothing personal.

But former acquaintances don’t generally send you a note officially severing relations, a letter notifying you to, “Forget about me. You won’t be seeing me again.”

If we got such a letter, we might actually be relieved. Chances are, though, that if we weren’t expecting it (or secretly wishing for it), we would wonder what it was about. Was there a quarrel we didn’t even know about?

Chances are we wouldn’t try too hard to find out what the problem was, though. Whatever we did manage to learn would probably be unpleasant and unfixable.

The same is true when patients ask us to send all their records. Most people stay, unless something propels them to move on. Absent a shift in geography or health insurance, whatever did overcome their inertia it is probably not something we want to know.

“This will happen to you,” I tell my students. “Count on it. Patients will ask for their records. They may send you a note of complaint. ‘You didn’t find the skin cancer on mother’s leg,’ they may say. Or else, ‘Your treatments were useless. I went to another doctor who actually knew what was wrong and gave me what I needed.’ ” Nowadays, people put such sentiments into unfavorable online reviews.

“When you get letters or read reviews like those,” I advise, “count to 10 before you respond. Then count to 10 again. Then don’t respond. I’ve tried doing it the other way and regretted it every time.

“Mostly, there’s no potential litigation involved,” I continue. “If there is a threatened suit, you’ll need an attorney to respond anyway. Otherwise, learn what you can from the patient’s disappointment, file the letter, note the review, send all the records, and move on.”

We doctors tend to be an ingratiating sort. Because we try to help people, we want them to like us. Many will, often to excess. But good as we ever get, try as hard as we can, not everybody will like us. That’s life, in and out of medical practice.

Rejection is never pleasant. Experience thickens the skin, but even then a signed request to “Send all my records” can sting. Even after all these years, it still does.

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.

In a previous column, I warned about the high cost of generic desonide. This month, I alert you to the many potential dangers of this drug. By the time I’m done, you may not want to go near the stuff.

To approve e-scribe refills, we all need to acknowledge warnings and dangers and click “Benefit outweighs risk” or “Previously tolerated” or some other option. But some of these warnings make me wonder who on earth writes them.

Desonide comes with more warnings than almost any other medicine I prescribe electronically. I counted 21 such warnings. Here are some examples:

1. Desonide External Cream 0.05% should be used cautiously in Bacterial Infection, especially in Systemic Bacterial Infection. Since Folliculitis is a specific form of Bacterial Infection, the same precaution may apply.

I confess that I never thought of prescribing desonide for Bacterial Infection, Systemic or otherwise. Have you? (By the way, what’s with the excess use of capital letters?)

The second warning is even more dramatic.

2. Desonide External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection.

What makes this even more curious is the Viral Infections the warnings go on to enumerate.

2a. Since Actinic Keratosis is a specific form of Viral Infection, the same precaution may apply.

Actinic Keratosis is a Viral Infection? I didn’t know that.

3. Since Actinic Keratosis of the Hands and Arms is a specific form of Viral Infection, the same precaution may apply.

Now we learn of different subgroups of Actinic Keratoses that are Viral Infections. Did they teach you these in Dermatology School? (Please see Warnings 6-10, below.)

4. This warning refers to a specific Bacterial Infection called Folliculitis Nares Perforans. I don’t know what that is, but it sounds bad. Glad they warned me.

5. Since Pseudofolliculitis Barbae is a specific form of Bacterial Infection, the same precaution may apply.

I never used much desonide for pseudofolliculitis, cautiously or otherwise.

Warnings 6-10 describe more specific forms of Viral Infection: (6) Non-Hyperkeratotic Actinic Keratosis, (7) Actinic Keratosis of Face and Anterior Scalp, (8) Non-Hyperkeratotic Non-Pigmented Actinic Keratosis, (9) Non-Hyperkeratotic Face and Scalp Actinic Keratosis, (10) Pigmented Actinic Keratosis.

This is most disturbing. What Systemic Viral Infections did they leave me to use desonide on? Hyperkeratotic Non-Pigmented Actinic Keratoses of the Posterior Scalp?

Warning 11 is another specific Bacterial Infection: Local Folliculitis. What is the opposite of Local Folliculitis? Express Folliculitis?

Warning 12 is Perioral Dermatitis. Steroids on rosacea? Really? Maybe a cheaper one.

I will now skip to warning 16: Hirsutism has been associated with Desonide External Cream 0.05%. Since Hair Disease is a more general form of Hirsutism, it may also be considered a drug-related medical condition.

Did you know that desonide causes unwanted hair growth? Or realize that Hair Disease is a more general form of Hirsutism? I myself have male-pattern baldness. (Sorry, Male-Pattern BALDNESS.) Since Baldness is a Hair Disease, is it also a more general form of Hirsutism? Instead of having too little hair, do I now have too much?

The same is true for warning 17, which is identical to 16, except that it substitutes “Hypertrichosis” for “Hirsutism.”

Okay, colleagues, it’s time for a personal reckoning. You trained, practiced, took CME, but you didn’t know about any of these risks, did you? You’ve just been just heedlessly, incautiously, throwing around desonide, producing hairy patients with Systemic Bacterial and Viral Infections. And on “Non-Hyperkeratotic Non-Pigmented Actinic Keratosis,” no less. Aren’t you disappointed in yourselves?

When I first read warnings like these, I wrote my EMR provider to ask who puts together this stuff, and which consultants vet it. They never answered. It is very hard to believe that a dermatologist was involved at any stage of developing these warnings, with their irrelevant caveats and absurd classification schemes.

Who would develop electronic prescribing guidelines without at least consulting the physicians who do the prescribing? Why would they want to?

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.

In a previous column, I warned about the high cost of generic desonide. This month, I alert you to the many potential dangers of this drug. By the time I’m done, you may not want to go near the stuff.

To approve e-scribe refills, we all need to acknowledge warnings and dangers and click “Benefit outweighs risk” or “Previously tolerated” or some other option. But some of these warnings make me wonder who on earth writes them.

Desonide comes with more warnings than almost any other medicine I prescribe electronically. I counted 21 such warnings. Here are some examples:

1. Desonide External Cream 0.05% should be used cautiously in Bacterial Infection, especially in Systemic Bacterial Infection. Since Folliculitis is a specific form of Bacterial Infection, the same precaution may apply.

I confess that I never thought of prescribing desonide for Bacterial Infection, Systemic or otherwise. Have you? (By the way, what’s with the excess use of capital letters?)

The second warning is even more dramatic.

2. Desonide External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection.

What makes this even more curious is the Viral Infections the warnings go on to enumerate.

2a. Since Actinic Keratosis is a specific form of Viral Infection, the same precaution may apply.

Actinic Keratosis is a Viral Infection? I didn’t know that.

3. Since Actinic Keratosis of the Hands and Arms is a specific form of Viral Infection, the same precaution may apply.

Now we learn of different subgroups of Actinic Keratoses that are Viral Infections. Did they teach you these in Dermatology School? (Please see Warnings 6-10, below.)

4. This warning refers to a specific Bacterial Infection called Folliculitis Nares Perforans. I don’t know what that is, but it sounds bad. Glad they warned me.

5. Since Pseudofolliculitis Barbae is a specific form of Bacterial Infection, the same precaution may apply.

I never used much desonide for pseudofolliculitis, cautiously or otherwise.

Warnings 6-10 describe more specific forms of Viral Infection: (6) Non-Hyperkeratotic Actinic Keratosis, (7) Actinic Keratosis of Face and Anterior Scalp, (8) Non-Hyperkeratotic Non-Pigmented Actinic Keratosis, (9) Non-Hyperkeratotic Face and Scalp Actinic Keratosis, (10) Pigmented Actinic Keratosis.

This is most disturbing. What Systemic Viral Infections did they leave me to use desonide on? Hyperkeratotic Non-Pigmented Actinic Keratoses of the Posterior Scalp?

Warning 11 is another specific Bacterial Infection: Local Folliculitis. What is the opposite of Local Folliculitis? Express Folliculitis?

Warning 12 is Perioral Dermatitis. Steroids on rosacea? Really? Maybe a cheaper one.

I will now skip to warning 16: Hirsutism has been associated with Desonide External Cream 0.05%. Since Hair Disease is a more general form of Hirsutism, it may also be considered a drug-related medical condition.

Did you know that desonide causes unwanted hair growth? Or realize that Hair Disease is a more general form of Hirsutism? I myself have male-pattern baldness. (Sorry, Male-Pattern BALDNESS.) Since Baldness is a Hair Disease, is it also a more general form of Hirsutism? Instead of having too little hair, do I now have too much?

The same is true for warning 17, which is identical to 16, except that it substitutes “Hypertrichosis” for “Hirsutism.”

Okay, colleagues, it’s time for a personal reckoning. You trained, practiced, took CME, but you didn’t know about any of these risks, did you? You’ve just been just heedlessly, incautiously, throwing around desonide, producing hairy patients with Systemic Bacterial and Viral Infections. And on “Non-Hyperkeratotic Non-Pigmented Actinic Keratosis,” no less. Aren’t you disappointed in yourselves?

When I first read warnings like these, I wrote my EMR provider to ask who puts together this stuff, and which consultants vet it. They never answered. It is very hard to believe that a dermatologist was involved at any stage of developing these warnings, with their irrelevant caveats and absurd classification schemes.

Who would develop electronic prescribing guidelines without at least consulting the physicians who do the prescribing? Why would they want to?

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.

In a previous column, I warned about the high cost of generic desonide. This month, I alert you to the many potential dangers of this drug. By the time I’m done, you may not want to go near the stuff.

To approve e-scribe refills, we all need to acknowledge warnings and dangers and click “Benefit outweighs risk” or “Previously tolerated” or some other option. But some of these warnings make me wonder who on earth writes them.

Desonide comes with more warnings than almost any other medicine I prescribe electronically. I counted 21 such warnings. Here are some examples:

1. Desonide External Cream 0.05% should be used cautiously in Bacterial Infection, especially in Systemic Bacterial Infection. Since Folliculitis is a specific form of Bacterial Infection, the same precaution may apply.

I confess that I never thought of prescribing desonide for Bacterial Infection, Systemic or otherwise. Have you? (By the way, what’s with the excess use of capital letters?)

The second warning is even more dramatic.

2. Desonide External Cream 0.05% should be used cautiously in Viral Infection, especially in Systemic Viral Infection.

What makes this even more curious is the Viral Infections the warnings go on to enumerate.

2a. Since Actinic Keratosis is a specific form of Viral Infection, the same precaution may apply.

Actinic Keratosis is a Viral Infection? I didn’t know that.

3. Since Actinic Keratosis of the Hands and Arms is a specific form of Viral Infection, the same precaution may apply.

Now we learn of different subgroups of Actinic Keratoses that are Viral Infections. Did they teach you these in Dermatology School? (Please see Warnings 6-10, below.)

4. This warning refers to a specific Bacterial Infection called Folliculitis Nares Perforans. I don’t know what that is, but it sounds bad. Glad they warned me.

5. Since Pseudofolliculitis Barbae is a specific form of Bacterial Infection, the same precaution may apply.

I never used much desonide for pseudofolliculitis, cautiously or otherwise.

Warnings 6-10 describe more specific forms of Viral Infection: (6) Non-Hyperkeratotic Actinic Keratosis, (7) Actinic Keratosis of Face and Anterior Scalp, (8) Non-Hyperkeratotic Non-Pigmented Actinic Keratosis, (9) Non-Hyperkeratotic Face and Scalp Actinic Keratosis, (10) Pigmented Actinic Keratosis.

This is most disturbing. What Systemic Viral Infections did they leave me to use desonide on? Hyperkeratotic Non-Pigmented Actinic Keratoses of the Posterior Scalp?

Warning 11 is another specific Bacterial Infection: Local Folliculitis. What is the opposite of Local Folliculitis? Express Folliculitis?

Warning 12 is Perioral Dermatitis. Steroids on rosacea? Really? Maybe a cheaper one.

I will now skip to warning 16: Hirsutism has been associated with Desonide External Cream 0.05%. Since Hair Disease is a more general form of Hirsutism, it may also be considered a drug-related medical condition.

Did you know that desonide causes unwanted hair growth? Or realize that Hair Disease is a more general form of Hirsutism? I myself have male-pattern baldness. (Sorry, Male-Pattern BALDNESS.) Since Baldness is a Hair Disease, is it also a more general form of Hirsutism? Instead of having too little hair, do I now have too much?

The same is true for warning 17, which is identical to 16, except that it substitutes “Hypertrichosis” for “Hirsutism.”

Okay, colleagues, it’s time for a personal reckoning. You trained, practiced, took CME, but you didn’t know about any of these risks, did you? You’ve just been just heedlessly, incautiously, throwing around desonide, producing hairy patients with Systemic Bacterial and Viral Infections. And on “Non-Hyperkeratotic Non-Pigmented Actinic Keratosis,” no less. Aren’t you disappointed in yourselves?

When I first read warnings like these, I wrote my EMR provider to ask who puts together this stuff, and which consultants vet it. They never answered. It is very hard to believe that a dermatologist was involved at any stage of developing these warnings, with their irrelevant caveats and absurd classification schemes.

Who would develop electronic prescribing guidelines without at least consulting the physicians who do the prescribing? Why would they want to?

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.

“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”

“Yes!” she said.

I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.

Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.

Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.

“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.

“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.

“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.

Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.

“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.

“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.

“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.

“Your job is to know the options, watch their eyes, and negotiate,” I said.

My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.

Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”

These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:

• Are there pimples, pustules, whiteheads, blackheads, cysts?

• How many of each?

• Where they are – face, chest, back?

This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.

Here is what electronic medical records do not have you click off:

• Is the patient getting married soon?

• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?

• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?

They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.

So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.

More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.

As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.

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.

“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”

“Yes!” she said.

I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.

Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.

Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.

“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.

“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.

“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.

Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.

“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.

“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.

“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.

“Your job is to know the options, watch their eyes, and negotiate,” I said.

My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.

Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”

These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:

• Are there pimples, pustules, whiteheads, blackheads, cysts?

• How many of each?

• Where they are – face, chest, back?

This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.

Here is what electronic medical records do not have you click off:

• Is the patient getting married soon?

• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?

• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?

They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.

So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.

More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.

As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.

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.

“So tell me, Kathy,” I asked as I walked in. “Is the wedding still on?”

“Yes!” she said.

I was kidding, of course. I wanted to defuse the tension every bride feels as her big day approaches. With her nuptials 2 months off, Kathy was here for an acne tune-up.

Good news: no new pimples. Though Kathy had stopped squeezing her old ones, their marks were fading slowly. Brides don’t want to depend on makeup or Photoshop.

Her current regimen was a topical antibiotic in the morning and a retinoid at night. The question was whether to add or change anything.

“Maybe we should consider adding an oral medicine to help speed healing?” I asked. Then I watched her eyes. Her frown gave me my answer.

“I’d prefer to avoid oral medications unless I absolutely need them,” Kathy said.

“No problem,” I said. “You’re doing well, and we still have 2 months for the marks you have to fade.” I arranged to see her again shortly before the wedding, for any last-minute adjustments.

Outside the exam room, I took my student aside. “That’s how you negotiate,” I told her.

“Some young women approach their weddings in a kind of panic. They want to do whatever it takes to speed healing. If Kathy had felt that way, and I told her things were fine as they were, she would have been upset. ‘Isn’t there something else we can do, maybe something to take by mouth?’ she’d have asked.

“Instead, Kathy felt the opposite,” I told my student. “When patients have a specific problem, you can make a shrewd guess about how aggressive they want to be in addressing it. But you can’t be sure. That means watching their eyes and body language when making suggestions.

“Of course, not every medical condition is negotiable. Sometimes, the matter is so urgent or dire that there really is only one thing to do. Then you have to be more direct. But many situations are not so clear cut. You and the patient will have choices. Which is best may depend less on the medical condition than on the patient’s mindset and circumstances.

“Your job is to know the options, watch their eyes, and negotiate,” I said.

My student nodded, probably noticing that this is not standard clinical advice. In school, they teach you to make the right diagnosis and prescribe the treatment of choice. Anything else would be substandard care, a dereliction of professional duty.

Nowadays, teachers – and insurers – go in for algorithms, cookbook medicine. If the patient has this, do this. If that, do that. “How do you treat acne?” students often ask at the start of their rotation. “Can you give me a decision tree?”

These days more and more doctors spend their visit time clicking tablets or laptops. If the patient has acne, they are checking off vital data points like:

• Are there pimples, pustules, whiteheads, blackheads, cysts?

• How many of each?

• Where they are – face, chest, back?

This information is supposed to objectively describe and grade the patient’s acne. You click what is important: what you can count and measure.

Here is what electronic medical records do not have you click off:

• Is the patient getting married soon?

• Is she afraid of oral antibiotics because she’s heard they wreck your immune system and make you sick?

• Have her friends recommended an acne cream they are sure is the best thing since sliced tretinoin?

They don’t make boxes for what goes on inside people’s brains. You can’t count or measure that, and if you can’t count it, it doesn’t count.

So doctors click what they tell us to. As we click the keyboard, we are not looking at the patient’s face. So we don’t know whether the patient is buying what we have to offer.

More medical treatment than we care to admit is – or should be – a process of negotiation. Negotiating means looking people in the eye and hearing what they say and the way they say it. That way you know not only what they have, but what they want. In Kathy’s case, that would be a wedding to remember.

As she proceeds in her career, my student may do more than counting pimples and grading acne. At any rate, I hope so.

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.

The other day I had a chat with a chiropractor I’ll call Stan. Stan was excited about a new technique he has used to build his practice, whose clients now number several celebrities (some of whom I’d even heard of). “I specialize in muscular work and performance enhancement,” he said. “Performers with strenuous routines and a lot of stress need to sustain peak performance.”

A colleague out West whom Stan described as “very brilliant” had developed this technique. “It’s patented,” he said.

Stan went on to describe how this method has given him a whole new sense of the body. “I can actually feel the small transverse muscles of the vertebrae respond under my fingers,” he said. “The results are amazing.”

“How did you learn this technique?” I asked him.

“I took courses with the inventor,” he said. “His courses are patented, and can only be taught by accredited instructors. That ensures that the method is being done right. There are nine levels of certification.”

“Nine?”

“Yes, you have to keep taking more courses, learning new things. It’s very exciting.”

“By the way,” I asked, “how do you know that this method works better than the older ones you learned when you went to school?”

“Oh, you can feel and see the difference,” he said. “If you’re asking if there are studies or things like that, I guess there aren’t. But there’s no question that it’s better.”

“Do they teach this technique in chiropractic school?”

“No. As I said, it’s patented.”

“In that case,” I said, “it seems your professional schools are teaching inferior treatment methods.”

That gave Stan some pause. While he was thinking, I continued.

“It’s interesting,” I said. “In my profession, if someone came up with a treatment that was better than what everyone else was doing, he would need to do studies that proved he was right. He would also feel ethically bound to let everyone else know about the method, so all patients could be treated that way.”

Stan’s blank look suggested that this line of analysis had not occurred to him.

“But you must have some special techniques you use in your practice,” he said.

“No,” I said, “actually I don’t. I just practice conventional dermatology. Nothing special or unique about what I do.”

“What about the teaching hospitals in Boston,” he went on. “Don’t they do things no one else does?”

“Possibly,” I said. “But if they come up with a new technique, they have to convince others in the profession – and insurance companies – that their innovation is better in some measurable way.”

I’d gone as far as I wanted to. “It’s exciting that your patients do so well,” I said. “By the way,” I said, “what are celebrities really like up close and personal?”

“Most of them are very nice people,” he said. “They work hard to be good at what they do.”

“Do they ever complain that your treatment didn’t work, didn’t give their performance the boost they were expecting?”

“No,” he said. “Not one. They’re all happy.”

“That is really amazing,” I said. Stan nodded in agreement, though I don’t think he knew what I found so remarkable about it.

Stan is no cynic. He truly believes that what he does is valid, and that it helps his patients more than other treatments do. His patients believe it too.

Nor is our own profession as selfless and sharing as I made it sound. Hospitals love to trumpet their cyberknife technology or state-of-the-art orthopedic techniques or comprehensive cancer care, implying that they do whatever they do better than anyone else can.

Patients love to read this. They want to believe they’re seeing the “top” doctor, the one with the best results. Boston magazine (and the equivalent in every other city) publishes a list of “Top Doctors” this time of year.

Patients sometimes say, “I came to you because you did such a great job clearing up my sister’s acne,” or “You cleared my older son’s wart when nobody else could – one freeze, and it was gone. You’re a miracle worker!”

Oh sure I am. Nobody sprays liquid nitrogen the way I do.

I didn’t patent it, though. Teddy Roosevelt banned patent medicines in this country in 1906. But I guess in some quarters, patented never has gone away.

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.

The other day I had a chat with a chiropractor I’ll call Stan. Stan was excited about a new technique he has used to build his practice, whose clients now number several celebrities (some of whom I’d even heard of). “I specialize in muscular work and performance enhancement,” he said. “Performers with strenuous routines and a lot of stress need to sustain peak performance.”

A colleague out West whom Stan described as “very brilliant” had developed this technique. “It’s patented,” he said.

Stan went on to describe how this method has given him a whole new sense of the body. “I can actually feel the small transverse muscles of the vertebrae respond under my fingers,” he said. “The results are amazing.”

“How did you learn this technique?” I asked him.

“I took courses with the inventor,” he said. “His courses are patented, and can only be taught by accredited instructors. That ensures that the method is being done right. There are nine levels of certification.”

“Nine?”

“Yes, you have to keep taking more courses, learning new things. It’s very exciting.”

“By the way,” I asked, “how do you know that this method works better than the older ones you learned when you went to school?”

“Oh, you can feel and see the difference,” he said. “If you’re asking if there are studies or things like that, I guess there aren’t. But there’s no question that it’s better.”

“Do they teach this technique in chiropractic school?”

“No. As I said, it’s patented.”

“In that case,” I said, “it seems your professional schools are teaching inferior treatment methods.”

That gave Stan some pause. While he was thinking, I continued.

“It’s interesting,” I said. “In my profession, if someone came up with a treatment that was better than what everyone else was doing, he would need to do studies that proved he was right. He would also feel ethically bound to let everyone else know about the method, so all patients could be treated that way.”

Stan’s blank look suggested that this line of analysis had not occurred to him.

“But you must have some special techniques you use in your practice,” he said.

“No,” I said, “actually I don’t. I just practice conventional dermatology. Nothing special or unique about what I do.”

“What about the teaching hospitals in Boston,” he went on. “Don’t they do things no one else does?”

“Possibly,” I said. “But if they come up with a new technique, they have to convince others in the profession – and insurance companies – that their innovation is better in some measurable way.”

I’d gone as far as I wanted to. “It’s exciting that your patients do so well,” I said. “By the way,” I said, “what are celebrities really like up close and personal?”

“Most of them are very nice people,” he said. “They work hard to be good at what they do.”

“Do they ever complain that your treatment didn’t work, didn’t give their performance the boost they were expecting?”

“No,” he said. “Not one. They’re all happy.”

“That is really amazing,” I said. Stan nodded in agreement, though I don’t think he knew what I found so remarkable about it.

Stan is no cynic. He truly believes that what he does is valid, and that it helps his patients more than other treatments do. His patients believe it too.

Nor is our own profession as selfless and sharing as I made it sound. Hospitals love to trumpet their cyberknife technology or state-of-the-art orthopedic techniques or comprehensive cancer care, implying that they do whatever they do better than anyone else can.

Patients love to read this. They want to believe they’re seeing the “top” doctor, the one with the best results. Boston magazine (and the equivalent in every other city) publishes a list of “Top Doctors” this time of year.

Patients sometimes say, “I came to you because you did such a great job clearing up my sister’s acne,” or “You cleared my older son’s wart when nobody else could – one freeze, and it was gone. You’re a miracle worker!”

Oh sure I am. Nobody sprays liquid nitrogen the way I do.

I didn’t patent it, though. Teddy Roosevelt banned patent medicines in this country in 1906. But I guess in some quarters, patented never has gone away.

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.

The other day I had a chat with a chiropractor I’ll call Stan. Stan was excited about a new technique he has used to build his practice, whose clients now number several celebrities (some of whom I’d even heard of). “I specialize in muscular work and performance enhancement,” he said. “Performers with strenuous routines and a lot of stress need to sustain peak performance.”

A colleague out West whom Stan described as “very brilliant” had developed this technique. “It’s patented,” he said.

Stan went on to describe how this method has given him a whole new sense of the body. “I can actually feel the small transverse muscles of the vertebrae respond under my fingers,” he said. “The results are amazing.”

“How did you learn this technique?” I asked him.

“I took courses with the inventor,” he said. “His courses are patented, and can only be taught by accredited instructors. That ensures that the method is being done right. There are nine levels of certification.”

“Nine?”

“Yes, you have to keep taking more courses, learning new things. It’s very exciting.”

“By the way,” I asked, “how do you know that this method works better than the older ones you learned when you went to school?”

“Oh, you can feel and see the difference,” he said. “If you’re asking if there are studies or things like that, I guess there aren’t. But there’s no question that it’s better.”

“Do they teach this technique in chiropractic school?”

“No. As I said, it’s patented.”

“In that case,” I said, “it seems your professional schools are teaching inferior treatment methods.”

That gave Stan some pause. While he was thinking, I continued.

“It’s interesting,” I said. “In my profession, if someone came up with a treatment that was better than what everyone else was doing, he would need to do studies that proved he was right. He would also feel ethically bound to let everyone else know about the method, so all patients could be treated that way.”

Stan’s blank look suggested that this line of analysis had not occurred to him.

“But you must have some special techniques you use in your practice,” he said.

“No,” I said, “actually I don’t. I just practice conventional dermatology. Nothing special or unique about what I do.”

“What about the teaching hospitals in Boston,” he went on. “Don’t they do things no one else does?”

“Possibly,” I said. “But if they come up with a new technique, they have to convince others in the profession – and insurance companies – that their innovation is better in some measurable way.”

I’d gone as far as I wanted to. “It’s exciting that your patients do so well,” I said. “By the way,” I said, “what are celebrities really like up close and personal?”

“Most of them are very nice people,” he said. “They work hard to be good at what they do.”

“Do they ever complain that your treatment didn’t work, didn’t give their performance the boost they were expecting?”

“No,” he said. “Not one. They’re all happy.”

“That is really amazing,” I said. Stan nodded in agreement, though I don’t think he knew what I found so remarkable about it.

Stan is no cynic. He truly believes that what he does is valid, and that it helps his patients more than other treatments do. His patients believe it too.

Nor is our own profession as selfless and sharing as I made it sound. Hospitals love to trumpet their cyberknife technology or state-of-the-art orthopedic techniques or comprehensive cancer care, implying that they do whatever they do better than anyone else can.

Patients love to read this. They want to believe they’re seeing the “top” doctor, the one with the best results. Boston magazine (and the equivalent in every other city) publishes a list of “Top Doctors” this time of year.

Patients sometimes say, “I came to you because you did such a great job clearing up my sister’s acne,” or “You cleared my older son’s wart when nobody else could – one freeze, and it was gone. You’re a miracle worker!”

Oh sure I am. Nobody sprays liquid nitrogen the way I do.

I didn’t patent it, though. Teddy Roosevelt banned patent medicines in this country in 1906. But I guess in some quarters, patented never has gone away.

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.

As we all know, professional life gets more complicated every passing year. Meaningful use regulations grow more burdensome, even as the medical records we get fill up with electronic medical records boilerplate. To renew my medical license, my state board has me take a course in opioid management and end-of-life issues. Fill in your own examples.

But recently I’ve become aware of a new wrinkle that complicates daily practice life for both doctors and patients in a significant way. I can’t make any sense if it.

I mean the high price of desonide.

When I was student many years ago, my teachers told me that I should prescribe generic drugs whenever possible. This would help hold down medical costs. It was the right thing to do.

Because I am a good person who tries to do the right thing, I prescribe generics because it’s the right thing to do. I also do it for Pavlovian reasons: prescribing brand-name drugs means more prior authorization forms – we have enough of those anyway – and more calls from patients unhappy with high copays or other out-of-pocket costs. Also, fewer threats of sanctions from insurers or hospital purchasing groups over my pricey prescribing habits.

Besides, most patients I prescribe generics for do just fine.

Of course, some of the anomalous realities of generic prescribing filter through at times. Generic terbinafine and finasteride, for instance, may have higher profit margins, but don’t save patients much money.

But lately I’ve been getting complaints from patients about the high cost of desonide. My first reaction to these was, “How on earth is that possible?”

One patient a few months ago insisted that I contact his mail order pharmacy in Nevada to find a cheaper alternative. I considered this an unreasonable demand – I obviously can’t do a cost comparison for every patient, but this time I went along. The pharmacist came up with another nonfluorinated steroid that was much less expensive under that patient’s particular contract.

Then this week it happened again. I prescribed hydrocortisone valerate 0.2% for a groin rash. The patient left a message asking me for an over-the-counter suggestion, since the prescription was going to cost him $52.70 out of pocket.

I asked my secretary to call the pharmacy to get a price for other generic steroid creams. Triamcinolone would cost $14.70. Alclometasone would cost $35.20.

And desonide – generic desonide – would cost $111.70. For a 15-g tube. $111.70 for 15 g of a generic cream that’s been on the market forever! Does that make any sense?

I’ve gotten similar calls, by the way, from patients unhappy with the cost of generic doxycycline.

There are no doubt economic reasons for such pricing anomalies. Maybe generic manufacturers have dropped out of making certain drugs because they don’t make enough money on them, leaving the ones who remain in a position to charge whatever they can get away with. Maybe insurers or pharmacies cut deals with the makers of some drugs at the expense of others.

I don’t know. And that’s the point.

Because I have no way of knowing any more which of the plain-vanilla generic drugs I’ve prescribed forever are going to be fine, and which are going to cost my patients an arm and a leg and encourage them to call back and yell at me – or else not bother to pick up the medication at all – I don’t even know half the time what to recommend anymore. I certainly don’t have the time to go shopping for every prescription I order. There are just too many drugs, too many prescriptions, too many patients, too many pharmacies, too many insurance contracts, each with its own formulary quirks.

If anyone out there has any explanations or suggestions, I’m all ears.

In the meantime, I may try to simplify my life by sending all my patients to the local Russian deli and prescribing topical caviar. It’s likely to be cheaper than desonide. 

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.

As we all know, professional life gets more complicated every passing year. Meaningful use regulations grow more burdensome, even as the medical records we get fill up with electronic medical records boilerplate. To renew my medical license, my state board has me take a course in opioid management and end-of-life issues. Fill in your own examples.

But recently I’ve become aware of a new wrinkle that complicates daily practice life for both doctors and patients in a significant way. I can’t make any sense if it.

I mean the high price of desonide.

When I was student many years ago, my teachers told me that I should prescribe generic drugs whenever possible. This would help hold down medical costs. It was the right thing to do.

Because I am a good person who tries to do the right thing, I prescribe generics because it’s the right thing to do. I also do it for Pavlovian reasons: prescribing brand-name drugs means more prior authorization forms – we have enough of those anyway – and more calls from patients unhappy with high copays or other out-of-pocket costs. Also, fewer threats of sanctions from insurers or hospital purchasing groups over my pricey prescribing habits.

Besides, most patients I prescribe generics for do just fine.

Of course, some of the anomalous realities of generic prescribing filter through at times. Generic terbinafine and finasteride, for instance, may have higher profit margins, but don’t save patients much money.

But lately I’ve been getting complaints from patients about the high cost of desonide. My first reaction to these was, “How on earth is that possible?”

One patient a few months ago insisted that I contact his mail order pharmacy in Nevada to find a cheaper alternative. I considered this an unreasonable demand – I obviously can’t do a cost comparison for every patient, but this time I went along. The pharmacist came up with another nonfluorinated steroid that was much less expensive under that patient’s particular contract.

Then this week it happened again. I prescribed hydrocortisone valerate 0.2% for a groin rash. The patient left a message asking me for an over-the-counter suggestion, since the prescription was going to cost him $52.70 out of pocket.

I asked my secretary to call the pharmacy to get a price for other generic steroid creams. Triamcinolone would cost $14.70. Alclometasone would cost $35.20.

And desonide – generic desonide – would cost $111.70. For a 15-g tube. $111.70 for 15 g of a generic cream that’s been on the market forever! Does that make any sense?

I’ve gotten similar calls, by the way, from patients unhappy with the cost of generic doxycycline.

There are no doubt economic reasons for such pricing anomalies. Maybe generic manufacturers have dropped out of making certain drugs because they don’t make enough money on them, leaving the ones who remain in a position to charge whatever they can get away with. Maybe insurers or pharmacies cut deals with the makers of some drugs at the expense of others.

I don’t know. And that’s the point.

Because I have no way of knowing any more which of the plain-vanilla generic drugs I’ve prescribed forever are going to be fine, and which are going to cost my patients an arm and a leg and encourage them to call back and yell at me – or else not bother to pick up the medication at all – I don’t even know half the time what to recommend anymore. I certainly don’t have the time to go shopping for every prescription I order. There are just too many drugs, too many prescriptions, too many patients, too many pharmacies, too many insurance contracts, each with its own formulary quirks.

If anyone out there has any explanations or suggestions, I’m all ears.

In the meantime, I may try to simplify my life by sending all my patients to the local Russian deli and prescribing topical caviar. It’s likely to be cheaper than desonide. 

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.

As we all know, professional life gets more complicated every passing year. Meaningful use regulations grow more burdensome, even as the medical records we get fill up with electronic medical records boilerplate. To renew my medical license, my state board has me take a course in opioid management and end-of-life issues. Fill in your own examples.

But recently I’ve become aware of a new wrinkle that complicates daily practice life for both doctors and patients in a significant way. I can’t make any sense if it.

I mean the high price of desonide.

When I was student many years ago, my teachers told me that I should prescribe generic drugs whenever possible. This would help hold down medical costs. It was the right thing to do.

Because I am a good person who tries to do the right thing, I prescribe generics because it’s the right thing to do. I also do it for Pavlovian reasons: prescribing brand-name drugs means more prior authorization forms – we have enough of those anyway – and more calls from patients unhappy with high copays or other out-of-pocket costs. Also, fewer threats of sanctions from insurers or hospital purchasing groups over my pricey prescribing habits.

Besides, most patients I prescribe generics for do just fine.

Of course, some of the anomalous realities of generic prescribing filter through at times. Generic terbinafine and finasteride, for instance, may have higher profit margins, but don’t save patients much money.

But lately I’ve been getting complaints from patients about the high cost of desonide. My first reaction to these was, “How on earth is that possible?”

One patient a few months ago insisted that I contact his mail order pharmacy in Nevada to find a cheaper alternative. I considered this an unreasonable demand – I obviously can’t do a cost comparison for every patient, but this time I went along. The pharmacist came up with another nonfluorinated steroid that was much less expensive under that patient’s particular contract.

Then this week it happened again. I prescribed hydrocortisone valerate 0.2% for a groin rash. The patient left a message asking me for an over-the-counter suggestion, since the prescription was going to cost him $52.70 out of pocket.

I asked my secretary to call the pharmacy to get a price for other generic steroid creams. Triamcinolone would cost $14.70. Alclometasone would cost $35.20.

And desonide – generic desonide – would cost $111.70. For a 15-g tube. $111.70 for 15 g of a generic cream that’s been on the market forever! Does that make any sense?

I’ve gotten similar calls, by the way, from patients unhappy with the cost of generic doxycycline.

There are no doubt economic reasons for such pricing anomalies. Maybe generic manufacturers have dropped out of making certain drugs because they don’t make enough money on them, leaving the ones who remain in a position to charge whatever they can get away with. Maybe insurers or pharmacies cut deals with the makers of some drugs at the expense of others.

I don’t know. And that’s the point.

Because I have no way of knowing any more which of the plain-vanilla generic drugs I’ve prescribed forever are going to be fine, and which are going to cost my patients an arm and a leg and encourage them to call back and yell at me – or else not bother to pick up the medication at all – I don’t even know half the time what to recommend anymore. I certainly don’t have the time to go shopping for every prescription I order. There are just too many drugs, too many prescriptions, too many patients, too many pharmacies, too many insurance contracts, each with its own formulary quirks.

If anyone out there has any explanations or suggestions, I’m all ears.

In the meantime, I may try to simplify my life by sending all my patients to the local Russian deli and prescribing topical caviar. It’s likely to be cheaper than desonide. 

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.

In a recent column, I considered the different meanings some words we use every day can have when patients use them. The word I discussed was “biopsy.” There are, of course, many other words our patients use, or at least pronounce, differently than we do.

Many middle-aged men, for instance, have troubles with their prostrate.

Patients of both genders may be quite outgoing in general, but the cells in their skin cancers are squeamish.

And lots of people ask me to take a look at their molds. Or remove them. Or they write as a reason for “Why are you seeing the doctor today?” the answer “Check molds.”

Or sometimes patients tell me that the medicine I prescribed for their eczema not only hadn’t helped, but had exasperated things. (This works both ways. The other day a friend complained that his kids were really exacerbating him. As a parent, I can relate.)

And then there was Jim, who came in last month. “Dr. Skirball sent me over to have you look at this rash,” he said. “He wants you to do an autopsy.”

Well, Dr. Skirball was just going to have to wait, wasn’t he?

But then I saw Emma, who presented me with a linguistic insight I never heard before. Even after many years, patients can surprise you.

Emma is 17. She has acne. One glance showed that after 2 months of treatment, Emma wasn’t getting any better.

“Is the cream irritating you at all?” I asked.

“No,” she said. “I’m not using it, Doctor.”

OK, I thought. That happens often enough. I needed to find out why, though. Maybe I could convince her to try it after all.

“How come you didn’t use it?” I asked.

“I read the instructions that came with it,” Emma said, brightly. “And I followed them!”

“That’s great,” I said. “What do you mean?”

“Well, I read the small print at the end, and I saw that there was a warning: ‘Only for tropical use.’ ”

“What?”

“It said it was just for tropical use. And just around then it got kind of chilly, so I decided not to take a chance.”

I’ve seen plenty of people who read a label warning that says, “Avoid excessive sun exposure,” (whatever that means) and think they should stop the medicine every time the sun comes out. In fact, I always tell patients up front to ignore that warning, to follow routine sun precautions when relevant, and take the medicine.

And I’ve also heard plenty of people pronounce topical treatment, “tropical treatment.” Or refer to the branded version of desoximetasone as “Tropicort.”

But never, ever, had I met someone who not only mispronounced “topical” as “tropical,” but understood it as “of or pertaining to the tropics.” And then didn’t use the product, because they live in the temperate zone.

Besides, it’s late fall in Boston. What was Emma planning to do? Wait till next spring? Move to the Cayman Islands?

While we’re at it, why don’t many patients bother calling to tell us that the reason they’ve decided to stop using something we prescribed? But that’s another story.

“Emma,” I explained. “It’s not ‘tropical use.’ It’s ‘topical use.’ That just means you use it externally. On top of the skin.”

“Oh, I get it,” Emma said.

As I said, patients never cease to amaze. The weather’s gotten even chillier around here, but now that Emma will use the cream, we’ll see how she does. If she goes to Mexico for winter break, she’ll do even better.

Where is global warming when you need it?

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.

In a recent column, I considered the different meanings some words we use every day can have when patients use them. The word I discussed was “biopsy.” There are, of course, many other words our patients use, or at least pronounce, differently than we do.

Many middle-aged men, for instance, have troubles with their prostrate.

Patients of both genders may be quite outgoing in general, but the cells in their skin cancers are squeamish.

And lots of people ask me to take a look at their molds. Or remove them. Or they write as a reason for “Why are you seeing the doctor today?” the answer “Check molds.”

Or sometimes patients tell me that the medicine I prescribed for their eczema not only hadn’t helped, but had exasperated things. (This works both ways. The other day a friend complained that his kids were really exacerbating him. As a parent, I can relate.)

And then there was Jim, who came in last month. “Dr. Skirball sent me over to have you look at this rash,” he said. “He wants you to do an autopsy.”

Well, Dr. Skirball was just going to have to wait, wasn’t he?

But then I saw Emma, who presented me with a linguistic insight I never heard before. Even after many years, patients can surprise you.

Emma is 17. She has acne. One glance showed that after 2 months of treatment, Emma wasn’t getting any better.

“Is the cream irritating you at all?” I asked.

“No,” she said. “I’m not using it, Doctor.”

OK, I thought. That happens often enough. I needed to find out why, though. Maybe I could convince her to try it after all.

“How come you didn’t use it?” I asked.

“I read the instructions that came with it,” Emma said, brightly. “And I followed them!”

“That’s great,” I said. “What do you mean?”

“Well, I read the small print at the end, and I saw that there was a warning: ‘Only for tropical use.’ ”

“What?”

“It said it was just for tropical use. And just around then it got kind of chilly, so I decided not to take a chance.”

I’ve seen plenty of people who read a label warning that says, “Avoid excessive sun exposure,” (whatever that means) and think they should stop the medicine every time the sun comes out. In fact, I always tell patients up front to ignore that warning, to follow routine sun precautions when relevant, and take the medicine.

And I’ve also heard plenty of people pronounce topical treatment, “tropical treatment.” Or refer to the branded version of desoximetasone as “Tropicort.”

But never, ever, had I met someone who not only mispronounced “topical” as “tropical,” but understood it as “of or pertaining to the tropics.” And then didn’t use the product, because they live in the temperate zone.

Besides, it’s late fall in Boston. What was Emma planning to do? Wait till next spring? Move to the Cayman Islands?

While we’re at it, why don’t many patients bother calling to tell us that the reason they’ve decided to stop using something we prescribed? But that’s another story.

“Emma,” I explained. “It’s not ‘tropical use.’ It’s ‘topical use.’ That just means you use it externally. On top of the skin.”

“Oh, I get it,” Emma said.

As I said, patients never cease to amaze. The weather’s gotten even chillier around here, but now that Emma will use the cream, we’ll see how she does. If she goes to Mexico for winter break, she’ll do even better.

Where is global warming when you need it?

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.

In a recent column, I considered the different meanings some words we use every day can have when patients use them. The word I discussed was “biopsy.” There are, of course, many other words our patients use, or at least pronounce, differently than we do.

Many middle-aged men, for instance, have troubles with their prostrate.

Patients of both genders may be quite outgoing in general, but the cells in their skin cancers are squeamish.

And lots of people ask me to take a look at their molds. Or remove them. Or they write as a reason for “Why are you seeing the doctor today?” the answer “Check molds.”

Or sometimes patients tell me that the medicine I prescribed for their eczema not only hadn’t helped, but had exasperated things. (This works both ways. The other day a friend complained that his kids were really exacerbating him. As a parent, I can relate.)

And then there was Jim, who came in last month. “Dr. Skirball sent me over to have you look at this rash,” he said. “He wants you to do an autopsy.”

Well, Dr. Skirball was just going to have to wait, wasn’t he?

But then I saw Emma, who presented me with a linguistic insight I never heard before. Even after many years, patients can surprise you.

Emma is 17. She has acne. One glance showed that after 2 months of treatment, Emma wasn’t getting any better.

“Is the cream irritating you at all?” I asked.

“No,” she said. “I’m not using it, Doctor.”

OK, I thought. That happens often enough. I needed to find out why, though. Maybe I could convince her to try it after all.

“How come you didn’t use it?” I asked.

“I read the instructions that came with it,” Emma said, brightly. “And I followed them!”

“That’s great,” I said. “What do you mean?”

“Well, I read the small print at the end, and I saw that there was a warning: ‘Only for tropical use.’ ”

“What?”

“It said it was just for tropical use. And just around then it got kind of chilly, so I decided not to take a chance.”

I’ve seen plenty of people who read a label warning that says, “Avoid excessive sun exposure,” (whatever that means) and think they should stop the medicine every time the sun comes out. In fact, I always tell patients up front to ignore that warning, to follow routine sun precautions when relevant, and take the medicine.

And I’ve also heard plenty of people pronounce topical treatment, “tropical treatment.” Or refer to the branded version of desoximetasone as “Tropicort.”

But never, ever, had I met someone who not only mispronounced “topical” as “tropical,” but understood it as “of or pertaining to the tropics.” And then didn’t use the product, because they live in the temperate zone.

Besides, it’s late fall in Boston. What was Emma planning to do? Wait till next spring? Move to the Cayman Islands?

While we’re at it, why don’t many patients bother calling to tell us that the reason they’ve decided to stop using something we prescribed? But that’s another story.

“Emma,” I explained. “It’s not ‘tropical use.’ It’s ‘topical use.’ That just means you use it externally. On top of the skin.”

“Oh, I get it,” Emma said.

As I said, patients never cease to amaze. The weather’s gotten even chillier around here, but now that Emma will use the cream, we’ll see how she does. If she goes to Mexico for winter break, she’ll do even better.

Where is global warming when you need it?

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.

“When I use a word, it means just what I choose it to mean…” – Humpty Dumpty

Even after all these years, I’m still surprised to learn new ways the words we use every day can mean different things to patients to whom we say them.

Take the word “biopsy.” To a dermatologist, it means “a test of a piece of tissue” (in our case, of skin), to help find out what the problem is.

I’ve always known that to many patients, the word “biopsy” suggests cancer, or at least the concern that there may be cancer, because cancer is the context in which most people hear the word: breast biopsy, prostate biopsy, and so on. It can therefore be useful to point out to patients when a biopsy is performed for diagnostic purposes and cancer is not even on the list of possibilities.

Lately, though, I’ve had a few encounters that highlighted other interesting ways the word “biopsy” can be misunderstood.

Case 1: Arnold the Irritated

“Arnold,” I say. “I need to biopsy this. Based on the results, it may need further treatment, but I doubt it.”

“I thought you were taking it off now,” says Arnold.

“No, I’m testing it, “I say.

“But I want it off,” says Arnold. “It gets irritated when I shave over it, so I want it off.”

“Yes,” I say, “but in order to remove it properly, I need to know what it is.”

“What?”

We have to go around a few more times before Arnold catches on.

Case 2: Gaetano the Outraged

“Gaetano is on the phone,” says my billing clerk. “He says you told him you weren’t going to biopsy his spot, and then he got a bill from the pathology lab.”

I call Gaetano. “You said you weren’t going to biopsy this,” he says. “You said you were sure you knew what it was, so you didn’t have to biopsy it.”

“First of all,” I explain, “I’m never totally sure. Your spot looked like a basal cell skin cancer, and that’s what it turned out to be. But I’ve had cases where the pathology results surprised me, and it turned out to be something less – or something more. So I have to check the biopsy.”

“I understand, Doctor” says Gaetano.

“In addition,” I go on, “what I actually meant to say was that I was not going to only take a biopsy of the spot. I was going to remove it completely, so that if my diagnosis was confirmed, you wouldn’t have to come back and have more done. Sorry if I didn’t make that clear.”

“So you biopsied it,” says Gaetano, but you didn’t just biopsy it. I get it. I think.”

Good for you, Gaetano. Next time I am going to – actually, next time I don’t know what I’ll do.

Case 3: Melvin the Clueless

“I understand your former dermatologist removed something from your arm,” I say to Melvin.

“Yes, they took a biopsy, and then they removed it,” says Melvin. “I just have one question.”

“What is that?” I ask.

“Which was the biopsy?” asks Melvin, “the first or the second?”

I didn’t let on, but inside I was shaking my head.

Even with the best will on both sides – and even if both are native speakers of the same language – there are just so many ways people can misunderstand each other. Humpty Dumpty was wrong. Words can mean what both the talker and the listener think they mean. Humpty Dumpty probably didn’t get out much.

Never biopsy an egg. 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

“When I use a word, it means just what I choose it to mean…” – Humpty Dumpty

Even after all these years, I’m still surprised to learn new ways the words we use every day can mean different things to patients to whom we say them.

Take the word “biopsy.” To a dermatologist, it means “a test of a piece of tissue” (in our case, of skin), to help find out what the problem is.

I’ve always known that to many patients, the word “biopsy” suggests cancer, or at least the concern that there may be cancer, because cancer is the context in which most people hear the word: breast biopsy, prostate biopsy, and so on. It can therefore be useful to point out to patients when a biopsy is performed for diagnostic purposes and cancer is not even on the list of possibilities.

Lately, though, I’ve had a few encounters that highlighted other interesting ways the word “biopsy” can be misunderstood.

Case 1: Arnold the Irritated

“Arnold,” I say. “I need to biopsy this. Based on the results, it may need further treatment, but I doubt it.”

“I thought you were taking it off now,” says Arnold.

“No, I’m testing it, “I say.

“But I want it off,” says Arnold. “It gets irritated when I shave over it, so I want it off.”

“Yes,” I say, “but in order to remove it properly, I need to know what it is.”

“What?”

We have to go around a few more times before Arnold catches on.

Case 2: Gaetano the Outraged

“Gaetano is on the phone,” says my billing clerk. “He says you told him you weren’t going to biopsy his spot, and then he got a bill from the pathology lab.”

I call Gaetano. “You said you weren’t going to biopsy this,” he says. “You said you were sure you knew what it was, so you didn’t have to biopsy it.”

“First of all,” I explain, “I’m never totally sure. Your spot looked like a basal cell skin cancer, and that’s what it turned out to be. But I’ve had cases where the pathology results surprised me, and it turned out to be something less – or something more. So I have to check the biopsy.”

“I understand, Doctor” says Gaetano.

“In addition,” I go on, “what I actually meant to say was that I was not going to only take a biopsy of the spot. I was going to remove it completely, so that if my diagnosis was confirmed, you wouldn’t have to come back and have more done. Sorry if I didn’t make that clear.”

“So you biopsied it,” says Gaetano, but you didn’t just biopsy it. I get it. I think.”

Good for you, Gaetano. Next time I am going to – actually, next time I don’t know what I’ll do.

Case 3: Melvin the Clueless

“I understand your former dermatologist removed something from your arm,” I say to Melvin.

“Yes, they took a biopsy, and then they removed it,” says Melvin. “I just have one question.”

“What is that?” I ask.

“Which was the biopsy?” asks Melvin, “the first or the second?”

I didn’t let on, but inside I was shaking my head.

Even with the best will on both sides – and even if both are native speakers of the same language – there are just so many ways people can misunderstand each other. Humpty Dumpty was wrong. Words can mean what both the talker and the listener think they mean. Humpty Dumpty probably didn’t get out much.

Never biopsy an egg. 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

“When I use a word, it means just what I choose it to mean…” – Humpty Dumpty

Even after all these years, I’m still surprised to learn new ways the words we use every day can mean different things to patients to whom we say them.

Take the word “biopsy.” To a dermatologist, it means “a test of a piece of tissue” (in our case, of skin), to help find out what the problem is.

I’ve always known that to many patients, the word “biopsy” suggests cancer, or at least the concern that there may be cancer, because cancer is the context in which most people hear the word: breast biopsy, prostate biopsy, and so on. It can therefore be useful to point out to patients when a biopsy is performed for diagnostic purposes and cancer is not even on the list of possibilities.

Lately, though, I’ve had a few encounters that highlighted other interesting ways the word “biopsy” can be misunderstood.

Case 1: Arnold the Irritated

“Arnold,” I say. “I need to biopsy this. Based on the results, it may need further treatment, but I doubt it.”

“I thought you were taking it off now,” says Arnold.

“No, I’m testing it, “I say.

“But I want it off,” says Arnold. “It gets irritated when I shave over it, so I want it off.”

“Yes,” I say, “but in order to remove it properly, I need to know what it is.”

“What?”

We have to go around a few more times before Arnold catches on.

Case 2: Gaetano the Outraged

“Gaetano is on the phone,” says my billing clerk. “He says you told him you weren’t going to biopsy his spot, and then he got a bill from the pathology lab.”

I call Gaetano. “You said you weren’t going to biopsy this,” he says. “You said you were sure you knew what it was, so you didn’t have to biopsy it.”

“First of all,” I explain, “I’m never totally sure. Your spot looked like a basal cell skin cancer, and that’s what it turned out to be. But I’ve had cases where the pathology results surprised me, and it turned out to be something less – or something more. So I have to check the biopsy.”

“I understand, Doctor” says Gaetano.

“In addition,” I go on, “what I actually meant to say was that I was not going to only take a biopsy of the spot. I was going to remove it completely, so that if my diagnosis was confirmed, you wouldn’t have to come back and have more done. Sorry if I didn’t make that clear.”

“So you biopsied it,” says Gaetano, but you didn’t just biopsy it. I get it. I think.”

Good for you, Gaetano. Next time I am going to – actually, next time I don’t know what I’ll do.

Case 3: Melvin the Clueless

“I understand your former dermatologist removed something from your arm,” I say to Melvin.

“Yes, they took a biopsy, and then they removed it,” says Melvin. “I just have one question.”

“What is that?” I ask.

“Which was the biopsy?” asks Melvin, “the first or the second?”

I didn’t let on, but inside I was shaking my head.

Even with the best will on both sides – and even if both are native speakers of the same language – there are just so many ways people can misunderstand each other. Humpty Dumpty was wrong. Words can mean what both the talker and the listener think they mean. Humpty Dumpty probably didn’t get out much.

Never biopsy an egg. 

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Two disturbing patients came by last week.

The first was a frail old man. His daughter brought him. She said he’d been living in Florida and “shown up” on her doorstep.

As a dermatologist, I’m not often thrown by what I see, but this unfortunate man’s face was hard to look at, with a gaping hole where his left nasolabial fold should have been.

How long had the cancer been there to gouge that hole? How could he neglect it so long? What kind of relationship (or nonrelationship) with his child did it take for this to happen?

I didn’t pursue these questions. Instead, I referred him and his daughter to a skin oncology center where, I hoped, therapy could manage a situation whose severity could surely have been prevented.

Two days later, a Russian woman came in. Remarkably hale at the age of 95 years, she spoke no English. The man who accompanied her, a relative youngster in his mid-70’s, was not a relative, just a stranger who took pity on a fellow visitor to a Russian senior center. “She has two sons,” he explained, “but they live in Minnesota and Texas.”

Her problem was also a basal cell, but this one was on the back of her right ear, large but manageable. I arranged to remove the lesion and offered to speak with her sons. Neither ever called.

Disease is a physical problem in a social context. Patients often present with problems they ignored until other people insisted they take care of them. Parents bring their children. Women drag their husbands. Patients tolerate their itch until their coworkers get annoyed “at seeing me scratch like a monkey.” In situations like these – you can come up with many others – the problem is not just with the patients, but with the people in their vicinity. Sometimes there are people in patients’ lives who notice and care, who demand, “Have that looked at!” But what if nobody cares? Or what if there is no one around at all?

Factors like mental, family, and social dysfunction often underlie whether and to what extent the diseases we diagnose get treated. As practicing physicians, we have little control over such factors. We just try to manage what presents in our offices.

So we make assumptions– that patients can afford to see us, that they have the common sense to come, that they have family or friends who encourage them to come and make doing that possible.

In cases like the ones I’ve just described, these assumptions were wrong. The old man from Florida probably rarely left his apartment, and when he did people just looked away in disgust. He wasn’t their problem. In both cases family was nowhere to be found. How many such lonely and neglected people are there with no support systems, who don’t show up on our office doorstep until it is hard or impossible to take care of them?

I sometimes think back to a case that has haunted me since my early years, when I worked in several Boston-area health centers and sometimes made house calls in gritty neighborhoods. One day I was called to see a patient on the first floor of a rundown example of one of Boston’s wood-frame triple-deckers.

The front door was open. No one was around. I wandered past the parlor into a bedroom. There lay the patient: A woman in late middle age, lying on her back in a dirty nightgown, staring at the ceiling. That image has haunted me for 30 years.

I no longer remember what her skin problem was, just the pitiful sight of her and all the questions it raised: Where was everybody? Who looked after this woman? Who cooked for her, shopped for her? If I prescribed something, who would see that she got it and used it?

I didn’t know. Even if I did, there was nothing I could do about it. Doctors in practice can’t make families stay together, or weave a social safety net that neglected people don’t slip through.

When something lies beyond the scope of what you take to be your responsibility, it’s easier to look away. Now and then a neglected patient forces us to face our own limitations and pay attention to what we have been not looking at.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Two disturbing patients came by last week.

The first was a frail old man. His daughter brought him. She said he’d been living in Florida and “shown up” on her doorstep.

As a dermatologist, I’m not often thrown by what I see, but this unfortunate man’s face was hard to look at, with a gaping hole where his left nasolabial fold should have been.

How long had the cancer been there to gouge that hole? How could he neglect it so long? What kind of relationship (or nonrelationship) with his child did it take for this to happen?

I didn’t pursue these questions. Instead, I referred him and his daughter to a skin oncology center where, I hoped, therapy could manage a situation whose severity could surely have been prevented.

Two days later, a Russian woman came in. Remarkably hale at the age of 95 years, she spoke no English. The man who accompanied her, a relative youngster in his mid-70’s, was not a relative, just a stranger who took pity on a fellow visitor to a Russian senior center. “She has two sons,” he explained, “but they live in Minnesota and Texas.”

Her problem was also a basal cell, but this one was on the back of her right ear, large but manageable. I arranged to remove the lesion and offered to speak with her sons. Neither ever called.

Disease is a physical problem in a social context. Patients often present with problems they ignored until other people insisted they take care of them. Parents bring their children. Women drag their husbands. Patients tolerate their itch until their coworkers get annoyed “at seeing me scratch like a monkey.” In situations like these – you can come up with many others – the problem is not just with the patients, but with the people in their vicinity. Sometimes there are people in patients’ lives who notice and care, who demand, “Have that looked at!” But what if nobody cares? Or what if there is no one around at all?

Factors like mental, family, and social dysfunction often underlie whether and to what extent the diseases we diagnose get treated. As practicing physicians, we have little control over such factors. We just try to manage what presents in our offices.

So we make assumptions– that patients can afford to see us, that they have the common sense to come, that they have family or friends who encourage them to come and make doing that possible.

In cases like the ones I’ve just described, these assumptions were wrong. The old man from Florida probably rarely left his apartment, and when he did people just looked away in disgust. He wasn’t their problem. In both cases family was nowhere to be found. How many such lonely and neglected people are there with no support systems, who don’t show up on our office doorstep until it is hard or impossible to take care of them?

I sometimes think back to a case that has haunted me since my early years, when I worked in several Boston-area health centers and sometimes made house calls in gritty neighborhoods. One day I was called to see a patient on the first floor of a rundown example of one of Boston’s wood-frame triple-deckers.

The front door was open. No one was around. I wandered past the parlor into a bedroom. There lay the patient: A woman in late middle age, lying on her back in a dirty nightgown, staring at the ceiling. That image has haunted me for 30 years.

I no longer remember what her skin problem was, just the pitiful sight of her and all the questions it raised: Where was everybody? Who looked after this woman? Who cooked for her, shopped for her? If I prescribed something, who would see that she got it and used it?

I didn’t know. Even if I did, there was nothing I could do about it. Doctors in practice can’t make families stay together, or weave a social safety net that neglected people don’t slip through.

When something lies beyond the scope of what you take to be your responsibility, it’s easier to look away. Now and then a neglected patient forces us to face our own limitations and pay attention to what we have been not looking at.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Two disturbing patients came by last week.

The first was a frail old man. His daughter brought him. She said he’d been living in Florida and “shown up” on her doorstep.

As a dermatologist, I’m not often thrown by what I see, but this unfortunate man’s face was hard to look at, with a gaping hole where his left nasolabial fold should have been.

How long had the cancer been there to gouge that hole? How could he neglect it so long? What kind of relationship (or nonrelationship) with his child did it take for this to happen?

I didn’t pursue these questions. Instead, I referred him and his daughter to a skin oncology center where, I hoped, therapy could manage a situation whose severity could surely have been prevented.

Two days later, a Russian woman came in. Remarkably hale at the age of 95 years, she spoke no English. The man who accompanied her, a relative youngster in his mid-70’s, was not a relative, just a stranger who took pity on a fellow visitor to a Russian senior center. “She has two sons,” he explained, “but they live in Minnesota and Texas.”

Her problem was also a basal cell, but this one was on the back of her right ear, large but manageable. I arranged to remove the lesion and offered to speak with her sons. Neither ever called.

Disease is a physical problem in a social context. Patients often present with problems they ignored until other people insisted they take care of them. Parents bring their children. Women drag their husbands. Patients tolerate their itch until their coworkers get annoyed “at seeing me scratch like a monkey.” In situations like these – you can come up with many others – the problem is not just with the patients, but with the people in their vicinity. Sometimes there are people in patients’ lives who notice and care, who demand, “Have that looked at!” But what if nobody cares? Or what if there is no one around at all?

Factors like mental, family, and social dysfunction often underlie whether and to what extent the diseases we diagnose get treated. As practicing physicians, we have little control over such factors. We just try to manage what presents in our offices.

So we make assumptions– that patients can afford to see us, that they have the common sense to come, that they have family or friends who encourage them to come and make doing that possible.

In cases like the ones I’ve just described, these assumptions were wrong. The old man from Florida probably rarely left his apartment, and when he did people just looked away in disgust. He wasn’t their problem. In both cases family was nowhere to be found. How many such lonely and neglected people are there with no support systems, who don’t show up on our office doorstep until it is hard or impossible to take care of them?

I sometimes think back to a case that has haunted me since my early years, when I worked in several Boston-area health centers and sometimes made house calls in gritty neighborhoods. One day I was called to see a patient on the first floor of a rundown example of one of Boston’s wood-frame triple-deckers.

The front door was open. No one was around. I wandered past the parlor into a bedroom. There lay the patient: A woman in late middle age, lying on her back in a dirty nightgown, staring at the ceiling. That image has haunted me for 30 years.

I no longer remember what her skin problem was, just the pitiful sight of her and all the questions it raised: Where was everybody? Who looked after this woman? Who cooked for her, shopped for her? If I prescribed something, who would see that she got it and used it?

I didn’t know. Even if I did, there was nothing I could do about it. Doctors in practice can’t make families stay together, or weave a social safety net that neglected people don’t slip through.

When something lies beyond the scope of what you take to be your responsibility, it’s easier to look away. Now and then a neglected patient forces us to face our own limitations and pay attention to what we have been not looking at.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

Thursday was a rough day. Not for me, but for my front-desk personnel. I wouldn’t even have known about it, if Nilda hadn’t clued me in.

“I’m a preschool teacher,” she said, after asking about Botox for underarm sweating. “So I have a lot of patience. But your front-desk people are amazing.”

“What do you mean?” I asked her.

“This lady walks in without an appointment,” she said. “Several people are trying to check in, and she just waltzes over and says, ‘The doctor said I could come in whenever I wanted.’”

I smiled. “That’s Harriet. She’s worried that she has an infection. We make allowances for people over 90.”

“And then there was a woman who didn’t even want to be seen,” Nilda went on. “She’d gotten a bill she didn’t approve of, and she kept going on and on.

“Your secretary said she would call the insurance company to look into it, but the woman kept saying, ‘I’ve been a patient here for 20 years, and there’s never been a problem with the insurance.’

“It would have been fine for your secretary to politely tell the woman she’d take care of it, but now she had to get back to patients trying to register. But she didn’t lose her cool, just kept repeating that she would call the patient’s insurer and let her know.”

I thanked Nilda very much for the feedback. “Most people don’t bother to comment unless they have a complaint,” I said, “so I appreciate your taking the time to say something positive. I’ll be sure to pass it on.”

“And I thought preschool children were tough,” said Nilda.

At lunch, I asked the staff what had been going on.

“Must be a full moon,” said Irma, her eyes twinkling. “The registration desk was like a zoo, what with all the new patients and the old ones who hadn’t been here in years re-registering. And in the middle of it all, a lady whose husband had already checked in and sat down kept calling out, ‘Is Gustav next’?”

“The man sitting next to her – must have been Gustav himself – grumbled at her to please keep quiet, but she kept calling out, ‘Is Gustav next?’ 

“Then Dorit comes in, complaining about her bill. It turns out that her insurance changed in May, but she had forgotten about it, and she didn’t understand what the change would mean for payment. I told her I would call her insurer and find out.

“ ‘I’ve been a patient here for 20 years,’ she kept saying. ‘So don’t overcharge me!’

“I told her I would let her know what her insurer said and promised that we wouldn’t overcharge her on the copay.

“In the meantime, Harriet, the walk-in, kept standing in front of the window saying, ‘Doctor Rockoff said I could come in whenever I want, and my son-in-law took off work to bring me in and he’s waiting outside.’

“And while Harriet was saying that, the lady in the chair kept calling out, ‘Is Gustav next? Is Gustav next?’ ”

I smiled to myself, trying to think of which absurdist playwright could do justice to what went on that morning in my waiting room, and maybe on lots of mornings and afternoons in waiting rooms everywhere.

“You should know,” I told Irma and the rest of the staff, “that one of the patients commented on how well you all did. You handled all that insanity while staying cool and polite. Great job!”

Of course, we have to stay vigilant for rude or discourteous behavior on the part of our staff. But that same staff often protects us from some pretty unreasonable behavior that patients sometimes can throw at them. It makes sense to make a point of telling our front-desk representatives from time to time how much we appreciate the graceful way they handle the guff and allow us to focus on each patient in the exam room.

Meantime, I am working on my new drama, a sequel to Waiting for Godot. I will call it, Is Gustav Next?

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.

"How’s the radiology business?" I asked him.

"Two more years," he said. "I should be able to hang on."

"That bad?"

"We were taken over by the academic department of a big teaching hospital," Peter said.

"What’s the problem? They want you to publish papers?" I asked.

"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."

"Measure what?"

"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."

You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.

"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."

"How about you?" I asked him. "Have they made you an offer you can’t refuse?"

"Not yet," he said.

Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.

"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."

Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.

The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.

Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.

"Yes," he said. "They just set that up recently."

"How did you find out?" I asked him.

"They sent out a memo," he said.

In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.

"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"

"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."

To say that hanging around colleagues who talk this way is dispiriting would be an understatement.

Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."

"I can see why," I said. "Whom do they take it out on?"

"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."

We agreed that seemed the best strategy.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.

"How’s the radiology business?" I asked him.

"Two more years," he said. "I should be able to hang on."

"That bad?"

"We were taken over by the academic department of a big teaching hospital," Peter said.

"What’s the problem? They want you to publish papers?" I asked.

"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."

"Measure what?"

"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."

You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.

"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."

"How about you?" I asked him. "Have they made you an offer you can’t refuse?"

"Not yet," he said.

Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.

"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."

Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.

The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.

Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.

"Yes," he said. "They just set that up recently."

"How did you find out?" I asked him.

"They sent out a memo," he said.

In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.

"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"

"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."

To say that hanging around colleagues who talk this way is dispiriting would be an understatement.

Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."

"I can see why," I said. "Whom do they take it out on?"

"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."

We agreed that seemed the best strategy.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

I ran into Peter the other day. We weren’t close back in high school 50 years ago – Peter was a jock and I wasn’t – but both of us ended up in medicine.

"How’s the radiology business?" I asked him.

"Two more years," he said. "I should be able to hang on."

"That bad?"

"We were taken over by the academic department of a big teaching hospital," Peter said.

"What’s the problem? They want you to publish papers?" I asked.

"They’re not crazy," he said. "They know what kind of papers we’d write. They just want to measure things."

"Measure what?"

"Anything they can," he said. "Productivity, quality. They micromanage everything. We’re not a private practice anymore. We don’t call our own shots."

You hear a lot of talk these days about whether private practice can survive. Judging by anecdotal chats with colleagues in other specialties, I’d say prospects are iffy. A lot of the future is already here.

"I’m going crazy," a local community rheumatologist told me. "There was just one other guy in town. The local hospital knocked on his door and said, ‘Either sell out and work for us on our terms, or you’ll never get another referral.’ So he just closed up and moved out of state."

"How about you?" I asked him. "Have they made you an offer you can’t refuse?"

"Not yet," he said.

Then I met an oncologist from my wife’s family. He is a couple of years younger than I am. "I never thought I’d be working harder than I ever did at my age," he said. "And earning less.

"But we just sold our practice. No choice, really. Reimbursements don’t cover the cost of chemo drugs, so we lose money on every patient we give them to. The hospital that’s buying us can bill for drugs at a higher rate. So I’ll work for them for 5 years, then I’m out."

Then I heard about a neurologist, whose practice his hospital covets. He orders scans and other diagnostic procedures that generate hundreds of thousands of dollars annually, but that of course he can’t bill for. The hospital can. I don’t get how that works, but obviously the hospital does.

The trend toward consolidation proceeds. Doctors become salaried employees of large organizations. Maybe the main reason we dermatologists aren’t being swallowed yet by the big fish is that we’re just not tasty enough. We don’t generate admissions or enough costly procedures to make gulping us down worthwhile.

Switching from being an independent practitioner to a salaried employee means more than a change of location or even lower income; it signals a loss of status. I got a glimpse of how that plays out when I met another friend, an internist who used to be out on his own, but who now works for a big health care organization. "Have you got a quota of patients you have to meet?" I asked him.

"Yes," he said. "They just set that up recently."

"How did you find out?" I asked him.

"They sent out a memo," he said.

In other words, management notified doctors of productivity guidelines the same way that they would tell clerks or auxiliary personnel by which quality metrics their performance and salary would be judged.

"What if you don’t meet your quota because patients cancel or don’t keep their appointments?" I asked him. "You have no control over how patients are booked or reminded to come?"

"They blame the doctors anyway," he said. "Anyway, I’m not full time anymore. I’ll be retiring soon."

To say that hanging around colleagues who talk this way is dispiriting would be an understatement.

Peter the radiologist spoke in similar downbeat tones. "I’m adapting to the new reality fairly well," he said, "because I see the end in sight. But my younger colleagues are having a harder time. They thought they were joining a private practice, and none of them would have signed on for what they’re getting now: harder work, longer hours, no autonomy. They show up every morning cranky, muttering under their breath."

"I can see why," I said. "Whom do they take it out on?"

"Not the administrators," said Peter. "They don’t care. And certainly not the patients. They take it out on their families, I guess."

We agreed that seemed the best strategy.

Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Skin & Allergy News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.