Alan Rockoff, MD

At 16, Eddie is tall and athletic. He’s been treating closed comedones on his forehead and chest off and on for a couple of years.

"I hope you can help him," his mother says. "There are days when he won’t go to school, he’s so embarrassed."

Really?

If you sat people down and asked them to list what people hate about their bodies, they wouldn’t come close to guessing what we dermatologists run into every day. Here are some cases I’ve seen lately. I’m sure you can easily come up with your own examples.

• A 50-year-old attorney with a wart on the dorsum of his right hand wanted me to take it off. "I sign a lot of documents," he said," and I’d prefer that clients remember me for my legal skills, not the wart on my hand."

• A 36-year-old waiter with a picker’s nodule over the proximal interphalangeal joint of his left fifth finger said I just had to get rid of it. "I’m a waiter," he said. "This is killing my tips."

• A 36-year-old woman gave up yoga a year ago, because she was sure the woman on the adjacent mat was disgusted by her plantar warts.

• A sprightly retiree, age 88(!), insisted on paying out of pocket to remove dermatosis papulosa nigra lesions from her face. Her explanation? "My children want me to stay at home, but I want to get out and be social!"

Self-consciousness doesn’t require lesions. For instance, I saw an 11-year-old last month with widespread atopic dermatitis, the kind that’s lifelong, miserably itchy, and hard to control. Yet she wasn’t even being treated. Why had she come now?

"What bothers you most about this?" I asked her.

"This brown patch on my neck," she said.

That’s right – not the itch, not the scratching, not the staying awake at night. What bothered her was the postinflammatory pigmentation on her neck that other kids would see and comment on.

She’s not alone. Another mother brought her 8-year-old daughter to see me. The girl’s eczema was being treated with nothing but moisturizer (which was "working, sort of").

"The reason we’re here," said Mom, "is that now she is starting to get self-conscious about the dark staining on her hand."

As doctors, we’re trained to think functionally so we can measure the ways disease impairs functionality: length of life, duration of fever, days out of work, oxygen saturation, percentage of involved body surface.

But you can’t measure shame. Nor can you predict what will produce it. Even after all these years, people surprise me all the time.

The secondary codes some insurers demand to cover wart treatment include pain, rapid growth, or bleeding. They do not include, "Clients are staring at my hand at real estate closings." Or, "This bump is reducing my tips." We could, of course, tell people not to mind being stared at, but they will not agree. They know how people look at them, and what parts of them they look at.

If any of us had a big welt over one eye, we might think twice before going to work, knowing that every patient and staff member are going to ask, "What bar were you in, and what does the other guy look like?" The teenager with the stain on her neck and the boy with the papules on his forehead and chest feel that way every morning.

Basically, nobody wants to stand out. If we do, we’d like it to be for some admirable quality. The truth is, we shouldn’t really take credit for being called handsome, smart, or healthy, but we do anyway. By the same token, it’s not our fault if we’re ill or different, but being singled out for either makes things worse – not functionally, just humanly.

Many years ago, a 15-year-old girl asked me to take off a mole from the top of her foot.

"The mole’s fine," I said. "Why do you want it off?"

"It’s embarrassing," she said.

"How?" I asked her. "Don’t you go to pools in the summer?"

"I stand with the one foot covering the spot on the other foot. Nobody has ever seen it."

Not everything people are embarrassed about can be removed with a cream or a hyfrecator. But shame is powerful, and we need to recognize it for what it is so we can address it if we can.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

At 16, Eddie is tall and athletic. He’s been treating closed comedones on his forehead and chest off and on for a couple of years.

"I hope you can help him," his mother says. "There are days when he won’t go to school, he’s so embarrassed."

Really?

If you sat people down and asked them to list what people hate about their bodies, they wouldn’t come close to guessing what we dermatologists run into every day. Here are some cases I’ve seen lately. I’m sure you can easily come up with your own examples.

• A 50-year-old attorney with a wart on the dorsum of his right hand wanted me to take it off. "I sign a lot of documents," he said," and I’d prefer that clients remember me for my legal skills, not the wart on my hand."

• A 36-year-old waiter with a picker’s nodule over the proximal interphalangeal joint of his left fifth finger said I just had to get rid of it. "I’m a waiter," he said. "This is killing my tips."

• A 36-year-old woman gave up yoga a year ago, because she was sure the woman on the adjacent mat was disgusted by her plantar warts.

• A sprightly retiree, age 88(!), insisted on paying out of pocket to remove dermatosis papulosa nigra lesions from her face. Her explanation? "My children want me to stay at home, but I want to get out and be social!"

Self-consciousness doesn’t require lesions. For instance, I saw an 11-year-old last month with widespread atopic dermatitis, the kind that’s lifelong, miserably itchy, and hard to control. Yet she wasn’t even being treated. Why had she come now?

"What bothers you most about this?" I asked her.

"This brown patch on my neck," she said.

That’s right – not the itch, not the scratching, not the staying awake at night. What bothered her was the postinflammatory pigmentation on her neck that other kids would see and comment on.

She’s not alone. Another mother brought her 8-year-old daughter to see me. The girl’s eczema was being treated with nothing but moisturizer (which was "working, sort of").

"The reason we’re here," said Mom, "is that now she is starting to get self-conscious about the dark staining on her hand."

As doctors, we’re trained to think functionally so we can measure the ways disease impairs functionality: length of life, duration of fever, days out of work, oxygen saturation, percentage of involved body surface.

But you can’t measure shame. Nor can you predict what will produce it. Even after all these years, people surprise me all the time.

The secondary codes some insurers demand to cover wart treatment include pain, rapid growth, or bleeding. They do not include, "Clients are staring at my hand at real estate closings." Or, "This bump is reducing my tips." We could, of course, tell people not to mind being stared at, but they will not agree. They know how people look at them, and what parts of them they look at.

If any of us had a big welt over one eye, we might think twice before going to work, knowing that every patient and staff member are going to ask, "What bar were you in, and what does the other guy look like?" The teenager with the stain on her neck and the boy with the papules on his forehead and chest feel that way every morning.

Basically, nobody wants to stand out. If we do, we’d like it to be for some admirable quality. The truth is, we shouldn’t really take credit for being called handsome, smart, or healthy, but we do anyway. By the same token, it’s not our fault if we’re ill or different, but being singled out for either makes things worse – not functionally, just humanly.

Many years ago, a 15-year-old girl asked me to take off a mole from the top of her foot.

"The mole’s fine," I said. "Why do you want it off?"

"It’s embarrassing," she said.

"How?" I asked her. "Don’t you go to pools in the summer?"

"I stand with the one foot covering the spot on the other foot. Nobody has ever seen it."

Not everything people are embarrassed about can be removed with a cream or a hyfrecator. But shame is powerful, and we need to recognize it for what it is so we can address it if we can.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

At 16, Eddie is tall and athletic. He’s been treating closed comedones on his forehead and chest off and on for a couple of years.

"I hope you can help him," his mother says. "There are days when he won’t go to school, he’s so embarrassed."

Really?

If you sat people down and asked them to list what people hate about their bodies, they wouldn’t come close to guessing what we dermatologists run into every day. Here are some cases I’ve seen lately. I’m sure you can easily come up with your own examples.

• A 50-year-old attorney with a wart on the dorsum of his right hand wanted me to take it off. "I sign a lot of documents," he said," and I’d prefer that clients remember me for my legal skills, not the wart on my hand."

• A 36-year-old waiter with a picker’s nodule over the proximal interphalangeal joint of his left fifth finger said I just had to get rid of it. "I’m a waiter," he said. "This is killing my tips."

• A 36-year-old woman gave up yoga a year ago, because she was sure the woman on the adjacent mat was disgusted by her plantar warts.

• A sprightly retiree, age 88(!), insisted on paying out of pocket to remove dermatosis papulosa nigra lesions from her face. Her explanation? "My children want me to stay at home, but I want to get out and be social!"

Self-consciousness doesn’t require lesions. For instance, I saw an 11-year-old last month with widespread atopic dermatitis, the kind that’s lifelong, miserably itchy, and hard to control. Yet she wasn’t even being treated. Why had she come now?

"What bothers you most about this?" I asked her.

"This brown patch on my neck," she said.

That’s right – not the itch, not the scratching, not the staying awake at night. What bothered her was the postinflammatory pigmentation on her neck that other kids would see and comment on.

She’s not alone. Another mother brought her 8-year-old daughter to see me. The girl’s eczema was being treated with nothing but moisturizer (which was "working, sort of").

"The reason we’re here," said Mom, "is that now she is starting to get self-conscious about the dark staining on her hand."

As doctors, we’re trained to think functionally so we can measure the ways disease impairs functionality: length of life, duration of fever, days out of work, oxygen saturation, percentage of involved body surface.

But you can’t measure shame. Nor can you predict what will produce it. Even after all these years, people surprise me all the time.

The secondary codes some insurers demand to cover wart treatment include pain, rapid growth, or bleeding. They do not include, "Clients are staring at my hand at real estate closings." Or, "This bump is reducing my tips." We could, of course, tell people not to mind being stared at, but they will not agree. They know how people look at them, and what parts of them they look at.

If any of us had a big welt over one eye, we might think twice before going to work, knowing that every patient and staff member are going to ask, "What bar were you in, and what does the other guy look like?" The teenager with the stain on her neck and the boy with the papules on his forehead and chest feel that way every morning.

Basically, nobody wants to stand out. If we do, we’d like it to be for some admirable quality. The truth is, we shouldn’t really take credit for being called handsome, smart, or healthy, but we do anyway. By the same token, it’s not our fault if we’re ill or different, but being singled out for either makes things worse – not functionally, just humanly.

Many years ago, a 15-year-old girl asked me to take off a mole from the top of her foot.

"The mole’s fine," I said. "Why do you want it off?"

"It’s embarrassing," she said.

"How?" I asked her. "Don’t you go to pools in the summer?"

"I stand with the one foot covering the spot on the other foot. Nobody has ever seen it."

Not everything people are embarrassed about can be removed with a cream or a hyfrecator. But shame is powerful, and we need to recognize it for what it is so we can address it if we can.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years.

"Hard cases," say the lawyers, "make bad law." That means something like, "Legislation works better when it’s drafted in response to average circumstances, not extreme ones."

This adage applies to our profession, too. You can learn more about how to practice and teach medicine from average cases than from rare and strange ones. Hard cases can make any of us look foolish.

Peter e-mailed me the other day. I’d seen him 6 months ago for an eczematous rash on his back. Something funny about it, though: The distribution didn’t work, and it wasn’t scaly. No response to triamcinolone. Biopsy: Nonspecific inflammation. CBC: Elevated white cells at 15,600, mostly lymphs. Hmmm.

I referred him to an academic center. They presented him at Grand Rounds, and set him up for patch testing. He avoided what they asked him to, with little success.

"The oncologist says I have lymphoma," Peter’s e-mail to the patch test clinic read, copying me. He apologetically canceled his allergy clinic follow-up. "I hope for a good prognosis, although diagnosis has been delayed for several months. I hope my example will be of value for future patients."

Peter puts his regrets gently. How valuable will his lesson be? His case teaches that strange presentations of uncommon conditions can make even good and conscientious doctors look lame.

We all congratulate ourselves on "good pick-ups," the diagnostic coups that hit the nail on the head. Fair enough, but we understandably look away when we got it right by dumb luck or got it wrong.

That subcutaneous fullness we thought was fine, but which the patient insisted be removed (and turned out to be dermatofibrosarcoma protuberans). That dark spot that looked like all the others, only the patient was nervous because he was sure it had changed (melanoma). The funny rash that ended up being measles in an unimmunized child, and when was the last time you saw measles?

Often, we never even find out about the hard cases we missed, because the people who had them got fed up with us and went elsewhere. Sometimes, they send an angry letter or – more common these days – write a bad review. "I went to another doctor who finally figured out my problem and prescribed the right treatment." Once in a while, a lawsuit.

Viewed through the "retrospectoscope," knowing how the story turned out, our initial fumblings look pretty clumsy, if not downright actionable. "Oh, come on," a critic might say, "Surely that lump was too irregular for you to pass it off as a fibroma." Or: "Why the surprise? Didn’t he tell you the mole changed?" "The kid was sick and had a funny rash, didn’t she?" says a third. "Don’t you read the papers about all the parents who won’t vaccinate their children for fear of autism?"

I’m not suggesting that these are bad questions or that we shouldn’t ask them, so we can learn what we can. What I am saying is that, even if we do, no matter how careful and thoughtful we are, we are never going to catch everything we are unprepared for – the rare, the atypical, the unexpected.

This spring, the media reported details of an outbreak that occurred 5 years ago at New Orleans Children’s Hospital of what turned out to be mucormycosis; it proved fatal for several children. Looking back, mistakes were made. Diagnostic biopsies were only done when parents demanded them. Soiled laundry was mishandled. All this at a well-respected tertiary care center staffed by clinicians no doubt as fine as specialists anywhere.

The resulting investigation will no doubt find clinical and administrative gaps and address them. Consciousness will be raised, systems streamlined, oversight tightened. This loophole will be closed. Then others will open, no doubt the way they usually do, when people are looking at something else.

I knew there was something fishy about Peter’s case, but I didn’t know what it was. The experienced and thoughtful academic physicians I sent him to didn’t figure it out, either. It is nice of Peter to be philosophical about this. I would not begrudge him a less considerate reaction.

As for us, we ought to be vigilant, thorough, and humble. Should we get full of ourselves, there’s a hard case out there just waiting to deflate us.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

"Hard cases," say the lawyers, "make bad law." That means something like, "Legislation works better when it’s drafted in response to average circumstances, not extreme ones."

This adage applies to our profession, too. You can learn more about how to practice and teach medicine from average cases than from rare and strange ones. Hard cases can make any of us look foolish.

Peter e-mailed me the other day. I’d seen him 6 months ago for an eczematous rash on his back. Something funny about it, though: The distribution didn’t work, and it wasn’t scaly. No response to triamcinolone. Biopsy: Nonspecific inflammation. CBC: Elevated white cells at 15,600, mostly lymphs. Hmmm.

I referred him to an academic center. They presented him at Grand Rounds, and set him up for patch testing. He avoided what they asked him to, with little success.

"The oncologist says I have lymphoma," Peter’s e-mail to the patch test clinic read, copying me. He apologetically canceled his allergy clinic follow-up. "I hope for a good prognosis, although diagnosis has been delayed for several months. I hope my example will be of value for future patients."

Peter puts his regrets gently. How valuable will his lesson be? His case teaches that strange presentations of uncommon conditions can make even good and conscientious doctors look lame.

We all congratulate ourselves on "good pick-ups," the diagnostic coups that hit the nail on the head. Fair enough, but we understandably look away when we got it right by dumb luck or got it wrong.

That subcutaneous fullness we thought was fine, but which the patient insisted be removed (and turned out to be dermatofibrosarcoma protuberans). That dark spot that looked like all the others, only the patient was nervous because he was sure it had changed (melanoma). The funny rash that ended up being measles in an unimmunized child, and when was the last time you saw measles?

Often, we never even find out about the hard cases we missed, because the people who had them got fed up with us and went elsewhere. Sometimes, they send an angry letter or – more common these days – write a bad review. "I went to another doctor who finally figured out my problem and prescribed the right treatment." Once in a while, a lawsuit.

Viewed through the "retrospectoscope," knowing how the story turned out, our initial fumblings look pretty clumsy, if not downright actionable. "Oh, come on," a critic might say, "Surely that lump was too irregular for you to pass it off as a fibroma." Or: "Why the surprise? Didn’t he tell you the mole changed?" "The kid was sick and had a funny rash, didn’t she?" says a third. "Don’t you read the papers about all the parents who won’t vaccinate their children for fear of autism?"

I’m not suggesting that these are bad questions or that we shouldn’t ask them, so we can learn what we can. What I am saying is that, even if we do, no matter how careful and thoughtful we are, we are never going to catch everything we are unprepared for – the rare, the atypical, the unexpected.

This spring, the media reported details of an outbreak that occurred 5 years ago at New Orleans Children’s Hospital of what turned out to be mucormycosis; it proved fatal for several children. Looking back, mistakes were made. Diagnostic biopsies were only done when parents demanded them. Soiled laundry was mishandled. All this at a well-respected tertiary care center staffed by clinicians no doubt as fine as specialists anywhere.

The resulting investigation will no doubt find clinical and administrative gaps and address them. Consciousness will be raised, systems streamlined, oversight tightened. This loophole will be closed. Then others will open, no doubt the way they usually do, when people are looking at something else.

I knew there was something fishy about Peter’s case, but I didn’t know what it was. The experienced and thoughtful academic physicians I sent him to didn’t figure it out, either. It is nice of Peter to be philosophical about this. I would not begrudge him a less considerate reaction.

As for us, we ought to be vigilant, thorough, and humble. Should we get full of ourselves, there’s a hard case out there just waiting to deflate us.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

"Hard cases," say the lawyers, "make bad law." That means something like, "Legislation works better when it’s drafted in response to average circumstances, not extreme ones."

This adage applies to our profession, too. You can learn more about how to practice and teach medicine from average cases than from rare and strange ones. Hard cases can make any of us look foolish.

Peter e-mailed me the other day. I’d seen him 6 months ago for an eczematous rash on his back. Something funny about it, though: The distribution didn’t work, and it wasn’t scaly. No response to triamcinolone. Biopsy: Nonspecific inflammation. CBC: Elevated white cells at 15,600, mostly lymphs. Hmmm.

I referred him to an academic center. They presented him at Grand Rounds, and set him up for patch testing. He avoided what they asked him to, with little success.

"The oncologist says I have lymphoma," Peter’s e-mail to the patch test clinic read, copying me. He apologetically canceled his allergy clinic follow-up. "I hope for a good prognosis, although diagnosis has been delayed for several months. I hope my example will be of value for future patients."

Peter puts his regrets gently. How valuable will his lesson be? His case teaches that strange presentations of uncommon conditions can make even good and conscientious doctors look lame.

We all congratulate ourselves on "good pick-ups," the diagnostic coups that hit the nail on the head. Fair enough, but we understandably look away when we got it right by dumb luck or got it wrong.

That subcutaneous fullness we thought was fine, but which the patient insisted be removed (and turned out to be dermatofibrosarcoma protuberans). That dark spot that looked like all the others, only the patient was nervous because he was sure it had changed (melanoma). The funny rash that ended up being measles in an unimmunized child, and when was the last time you saw measles?

Often, we never even find out about the hard cases we missed, because the people who had them got fed up with us and went elsewhere. Sometimes, they send an angry letter or – more common these days – write a bad review. "I went to another doctor who finally figured out my problem and prescribed the right treatment." Once in a while, a lawsuit.

Viewed through the "retrospectoscope," knowing how the story turned out, our initial fumblings look pretty clumsy, if not downright actionable. "Oh, come on," a critic might say, "Surely that lump was too irregular for you to pass it off as a fibroma." Or: "Why the surprise? Didn’t he tell you the mole changed?" "The kid was sick and had a funny rash, didn’t she?" says a third. "Don’t you read the papers about all the parents who won’t vaccinate their children for fear of autism?"

I’m not suggesting that these are bad questions or that we shouldn’t ask them, so we can learn what we can. What I am saying is that, even if we do, no matter how careful and thoughtful we are, we are never going to catch everything we are unprepared for – the rare, the atypical, the unexpected.

This spring, the media reported details of an outbreak that occurred 5 years ago at New Orleans Children’s Hospital of what turned out to be mucormycosis; it proved fatal for several children. Looking back, mistakes were made. Diagnostic biopsies were only done when parents demanded them. Soiled laundry was mishandled. All this at a well-respected tertiary care center staffed by clinicians no doubt as fine as specialists anywhere.

The resulting investigation will no doubt find clinical and administrative gaps and address them. Consciousness will be raised, systems streamlined, oversight tightened. This loophole will be closed. Then others will open, no doubt the way they usually do, when people are looking at something else.

I knew there was something fishy about Peter’s case, but I didn’t know what it was. The experienced and thoughtful academic physicians I sent him to didn’t figure it out, either. It is nice of Peter to be philosophical about this. I would not begrudge him a less considerate reaction.

As for us, we ought to be vigilant, thorough, and humble. Should we get full of ourselves, there’s a hard case out there just waiting to deflate us.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Who do you call when your windshield’s busted?

Call Giant Glass!

There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.

Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"

If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.

Or why Beth Israel Deaconess is the Red Sox Official Hospital.

You can see where I’m going with this, can’t you?

In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)

I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.

*******************

Marriott Hotels

Dear Mr. or Ms. Marriott:

I salute you as Official Hotel of the Red Sox!

But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?

Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.

Our rates are reasonable. Give us a call!

*******************

Dunkin’ Donuts

Dear Donuts:

It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!

I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?

That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)

*******************

John Hancock Insurance

Dear Mr. Hancock,

Congratulations on being the Official Insurance of the Boston Red Sox.

I just love your building, a real Boston landmark.

Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)

While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.

Let’s do lunch. Do you like Dunkin’ Donuts?

*******************

You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.

Here’s a sample letter:

Toledo Mud Hens

Toledo, Ohio

Dear Mud Hens,

I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.

Let’s all get together and triangulate.

Go Mud Hens!

*******************

OK, colleagues, I’ve given you direction. Now get out there and make it happen!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Who do you call when your windshield’s busted?

Call Giant Glass!

There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.

Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"

If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.

Or why Beth Israel Deaconess is the Red Sox Official Hospital.

You can see where I’m going with this, can’t you?

In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)

I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.

*******************

Marriott Hotels

Dear Mr. or Ms. Marriott:

I salute you as Official Hotel of the Red Sox!

But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?

Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.

Our rates are reasonable. Give us a call!

*******************

Dunkin’ Donuts

Dear Donuts:

It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!

I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?

That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)

*******************

John Hancock Insurance

Dear Mr. Hancock,

Congratulations on being the Official Insurance of the Boston Red Sox.

I just love your building, a real Boston landmark.

Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)

While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.

Let’s do lunch. Do you like Dunkin’ Donuts?

*******************

You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.

Here’s a sample letter:

Toledo Mud Hens

Toledo, Ohio

Dear Mud Hens,

I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.

Let’s all get together and triangulate.

Go Mud Hens!

*******************

OK, colleagues, I’ve given you direction. Now get out there and make it happen!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Who do you call when your windshield’s busted?

Call Giant Glass!

There isn’t a Boston Red Sox fan on the planet who can’t sing that annoying jingle in his or her sleep. This is because, as they never tire of reminding us, Giant Glass is the Official Windshield Replacer of the Boston Red Sox.

Why does a baseball team need an Official Windshield Replacer? The announcers like to say, "Hey, Joe, that homer went over the Green Monster right onto Yawkey Way – somebody’s gonna have to fix their windshield!"

If that answer satisfies you, you might ponder why EMC is the Official Data Storage company for the team. Or why Benjamin Moore is the Official Paint. Or why Poland Spring is the Official Water.

Or why Beth Israel Deaconess is the Red Sox Official Hospital.

You can see where I’m going with this, can’t you?

In our increasingly complex and competitive environment (EHRs! ACOs!), your columnist is always on the lookout for ways to help you to get a leg up on the competition. (Branding! Online reviews!)

I have therefore embarked on an ambitious effort to become Official Dermatologist to the Official Sponsors of the Boston Red Sox. Follow my example, Colleagues.

*******************

Marriott Hotels

Dear Mr. or Ms. Marriott:

I salute you as Official Hotel of the Red Sox!

But suppose one of your guests uses a hotel Jacuzzi and comes down with nasty Pseudomonas folliculitis. It happens. Who ya gonna call?

Call Rockoff Dermatology! We’ll do the job right, fix up your guests fast, and explain why even state-of-the-art hot tub disinfection sometimes fails. Once the pustules go away, your guests will happily come back to you.

Our rates are reasonable. Give us a call!

*******************

Dunkin’ Donuts

Dear Donuts:

It has come to our notice that you are the Official Coffee of the Boston Red Sox. Good for you!

I should mention that I really like your coffee, especially the Pumpkin Blend you make around Thanksgiving. You might wonder why you need an Official Dermatologist. Well, most of your fine coffee beverages come with milk – and dairy products have been implicated in acne. Of course, the evidence is a little thin, but if one of your customers has a latte and breaks out in major zits, don’t you want to send them to a skin doctor who cares not just about the pimples, but about your corporate image?

That would be me! Let’s get together over a cup of Seattle’s Best. (Just kidding!)

*******************

John Hancock Insurance

Dear Mr. Hancock,

Congratulations on being the Official Insurance of the Boston Red Sox.

I just love your building, a real Boston landmark.

Here’s why you need an Official Dermatologist: You sell insurance – and we dermatologists know insurance. Between updating coverage, scanning insurance cards, and checking online eligibility, our patients spend way more time registering than they do being examined. (Hey, we’re skin doctors – How long do you think that takes?)

While patients are filling out all our forms, we can show them a list of all your fine insurance products. Synergy! Win-win! For faster service, you could even put an agent in our waiting room.

Let’s do lunch. Do you like Dunkin’ Donuts?

*******************

You get the idea. Just pick a popular institution in your area – opera company, sports team, bowling alley – whatever image you have in mind. Then contact them about sponsorship opportunities. Be the first one to do it, and have your agent nail down an exclusive.

Here’s a sample letter:

Toledo Mud Hens

Toledo, Ohio

Dear Mud Hens,

I am writing to suggest you consider having us [INSERT NAME] as Official Dermatology and Aesthetic Rejuvenation Center of the Toledo Mud Hens Baseball Club. We already have a close affiliation with Downtown Latte on South St. Clair Street, and are the exclusive providers of skin care to their clients who get breakouts from dairy products added to their fine coffees.

Let’s all get together and triangulate.

Go Mud Hens!

*******************

OK, colleagues, I’ve given you direction. Now get out there and make it happen!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

It was the worst of days. It was the best of days.

When I opened the mail one day last week, I found a letter from someone I’ll call Thelma. It read, in part:

"Last Monday you were kind enough to look at my rash, which you thought was just eczema. You gave me cream and asked me to e-mail you Thursday about my condition. When I did and said I was still itchy, you said I should stick with the same and that I could come back Monday, but I couldn’t wait because I itched so bad I couldn’t take it anymore. I saw another doctor Friday who said the patch was host to something called pityriasis rosea. He said the rash was so textbook it should have been picked up immediately. I had to be put on an oral steroid right away.

"I am so upset that I’m sending you back your bill [for a $15 co-pay] because I had to go to another doctor who could really help me."

I thought of a few choice words for my esteemed Friday colleague, but kept them to myself. A single scaly patch is a textbook case of pityriasis rosea? Oral steroids for pityriasis? Really?

As far as this patient is concerned, I must be a bum. Thirty-five years on the job, and I haven’t mastered the textbook yet.

Sunk in gloom, I opened an e-mail sent to my website by a patient I’ll call Louise:

"I suffer from psoriasis and have been to countless dermatologists since I was 8 years old. I recently had a terrible outbreak and was really hesitant to even go to a dermatologist because I’ve never been satisfied with any of them. Your associate is wonderful! I can’t say enough about her. She is warm, thorough, and really takes the time to sit with you and listen. You can tell she truly cares about her patients and loves her job."

I looked at the patient’s chart. What was the wonderful and satisfying treatment that my associate had prescribed to deal with this patient’s lifelong, recalcitrant psoriasis?

Betamethasone dipropionate cream 0.05%. Wow.

I e-mailed my associate at once and we shared a gratified chuckle. Guess no one ever thought of treating Louise’s psoriasis with a topical steroid before. We must be geniuses, right out there on the cutting edge.

So which are we, dear colleagues – geniuses or bums?

We’re neither, of course, which doesn’t stop our patients from forming firm opinions one way or the other. Which they can share by angry letter, fulsome e-mail, or, of course, any on-line reviews they can slip past the mysterious algorithms of the Yelps and Angie’s Lists of the world.

When I get messages like Thelma’s and Louise’s, I show them to my students and make three suggestions:

• Don’t try to look smart at someone else’s expense. Next time around a patient will be in somebody else’s office calling you a fool.

• Don’t respond to snippy patients’ complaints by contacting the complainer and trying to justify yourself. Learn something if you can, and move on.

• Be grateful for praise. Just don’t take it too seriously.

In the meantime, the insurers and assorted bureaucrats who run our lives these days are busy defining good care and claiming to measure it so they can reward quality and punish inefficiency. I’m sure they think they’re doing a fine job, although I remain deeply skeptical that what they choose to measure has much relevance to what actually goes on in offices like ours.

I could, of course, try to tell them why I think so. (I have tried, in fact.) Getting through to people with a completely different way of looking at things than yours is not very rewarding, even when large sums of money are not involved. I would have as good a chance of winning them over as I would of convincing Thelma that a scaly patch is not textbook pityriasis that needs prednisone and Louise that betamethasone cream is not the breakthrough that will change her life.

So: Not the best of times. Not the worst of times. Just another day at the office.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

It was the worst of days. It was the best of days.

When I opened the mail one day last week, I found a letter from someone I’ll call Thelma. It read, in part:

"Last Monday you were kind enough to look at my rash, which you thought was just eczema. You gave me cream and asked me to e-mail you Thursday about my condition. When I did and said I was still itchy, you said I should stick with the same and that I could come back Monday, but I couldn’t wait because I itched so bad I couldn’t take it anymore. I saw another doctor Friday who said the patch was host to something called pityriasis rosea. He said the rash was so textbook it should have been picked up immediately. I had to be put on an oral steroid right away.

"I am so upset that I’m sending you back your bill [for a $15 co-pay] because I had to go to another doctor who could really help me."

I thought of a few choice words for my esteemed Friday colleague, but kept them to myself. A single scaly patch is a textbook case of pityriasis rosea? Oral steroids for pityriasis? Really?

As far as this patient is concerned, I must be a bum. Thirty-five years on the job, and I haven’t mastered the textbook yet.

Sunk in gloom, I opened an e-mail sent to my website by a patient I’ll call Louise:

"I suffer from psoriasis and have been to countless dermatologists since I was 8 years old. I recently had a terrible outbreak and was really hesitant to even go to a dermatologist because I’ve never been satisfied with any of them. Your associate is wonderful! I can’t say enough about her. She is warm, thorough, and really takes the time to sit with you and listen. You can tell she truly cares about her patients and loves her job."

I looked at the patient’s chart. What was the wonderful and satisfying treatment that my associate had prescribed to deal with this patient’s lifelong, recalcitrant psoriasis?

Betamethasone dipropionate cream 0.05%. Wow.

I e-mailed my associate at once and we shared a gratified chuckle. Guess no one ever thought of treating Louise’s psoriasis with a topical steroid before. We must be geniuses, right out there on the cutting edge.

So which are we, dear colleagues – geniuses or bums?

We’re neither, of course, which doesn’t stop our patients from forming firm opinions one way or the other. Which they can share by angry letter, fulsome e-mail, or, of course, any on-line reviews they can slip past the mysterious algorithms of the Yelps and Angie’s Lists of the world.

When I get messages like Thelma’s and Louise’s, I show them to my students and make three suggestions:

• Don’t try to look smart at someone else’s expense. Next time around a patient will be in somebody else’s office calling you a fool.

• Don’t respond to snippy patients’ complaints by contacting the complainer and trying to justify yourself. Learn something if you can, and move on.

• Be grateful for praise. Just don’t take it too seriously.

In the meantime, the insurers and assorted bureaucrats who run our lives these days are busy defining good care and claiming to measure it so they can reward quality and punish inefficiency. I’m sure they think they’re doing a fine job, although I remain deeply skeptical that what they choose to measure has much relevance to what actually goes on in offices like ours.

I could, of course, try to tell them why I think so. (I have tried, in fact.) Getting through to people with a completely different way of looking at things than yours is not very rewarding, even when large sums of money are not involved. I would have as good a chance of winning them over as I would of convincing Thelma that a scaly patch is not textbook pityriasis that needs prednisone and Louise that betamethasone cream is not the breakthrough that will change her life.

So: Not the best of times. Not the worst of times. Just another day at the office.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

It was the worst of days. It was the best of days.

When I opened the mail one day last week, I found a letter from someone I’ll call Thelma. It read, in part:

"Last Monday you were kind enough to look at my rash, which you thought was just eczema. You gave me cream and asked me to e-mail you Thursday about my condition. When I did and said I was still itchy, you said I should stick with the same and that I could come back Monday, but I couldn’t wait because I itched so bad I couldn’t take it anymore. I saw another doctor Friday who said the patch was host to something called pityriasis rosea. He said the rash was so textbook it should have been picked up immediately. I had to be put on an oral steroid right away.

"I am so upset that I’m sending you back your bill [for a $15 co-pay] because I had to go to another doctor who could really help me."

I thought of a few choice words for my esteemed Friday colleague, but kept them to myself. A single scaly patch is a textbook case of pityriasis rosea? Oral steroids for pityriasis? Really?

As far as this patient is concerned, I must be a bum. Thirty-five years on the job, and I haven’t mastered the textbook yet.

Sunk in gloom, I opened an e-mail sent to my website by a patient I’ll call Louise:

"I suffer from psoriasis and have been to countless dermatologists since I was 8 years old. I recently had a terrible outbreak and was really hesitant to even go to a dermatologist because I’ve never been satisfied with any of them. Your associate is wonderful! I can’t say enough about her. She is warm, thorough, and really takes the time to sit with you and listen. You can tell she truly cares about her patients and loves her job."

I looked at the patient’s chart. What was the wonderful and satisfying treatment that my associate had prescribed to deal with this patient’s lifelong, recalcitrant psoriasis?

Betamethasone dipropionate cream 0.05%. Wow.

I e-mailed my associate at once and we shared a gratified chuckle. Guess no one ever thought of treating Louise’s psoriasis with a topical steroid before. We must be geniuses, right out there on the cutting edge.

So which are we, dear colleagues – geniuses or bums?

We’re neither, of course, which doesn’t stop our patients from forming firm opinions one way or the other. Which they can share by angry letter, fulsome e-mail, or, of course, any on-line reviews they can slip past the mysterious algorithms of the Yelps and Angie’s Lists of the world.

When I get messages like Thelma’s and Louise’s, I show them to my students and make three suggestions:

• Don’t try to look smart at someone else’s expense. Next time around a patient will be in somebody else’s office calling you a fool.

• Don’t respond to snippy patients’ complaints by contacting the complainer and trying to justify yourself. Learn something if you can, and move on.

• Be grateful for praise. Just don’t take it too seriously.

In the meantime, the insurers and assorted bureaucrats who run our lives these days are busy defining good care and claiming to measure it so they can reward quality and punish inefficiency. I’m sure they think they’re doing a fine job, although I remain deeply skeptical that what they choose to measure has much relevance to what actually goes on in offices like ours.

I could, of course, try to tell them why I think so. (I have tried, in fact.) Getting through to people with a completely different way of looking at things than yours is not very rewarding, even when large sums of money are not involved. I would have as good a chance of winning them over as I would of convincing Thelma that a scaly patch is not textbook pityriasis that needs prednisone and Louise that betamethasone cream is not the breakthrough that will change her life.

So: Not the best of times. Not the worst of times. Just another day at the office.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Students who spend a month with me always want a session on topical steroids, that great undiscovered world they have to know but dread to explore. They’ve all seen those tables of steroid potency based on the rabbit-ear bioassay. These run to long columns (or several pages) of small print ordering the steroid universe from the aristocracy of Class 1 ("Supernovacort" 0.015%) down through the midrange ("Mediocricort" 0.026% ointment is Class 2, while Mediocricort 0.026% cream is only Class 3), down to the humble "Trivialicort" 32%, which on a good day is just a measly Class 6. All those multisyllabic names and numbers and classes bewilder and intimidate the poor kids. Even their earnest medical-student memorization skills leave them in despair of mastering all this stuff.

I ask them to ponder a mini-scenario: Your patient was given a topical steroid cream. He says it didn’t work. List all possible explanations.

The next day we discuss their answers. Most students manage to come up with several types of reasons. Maybe the steroid didn’t work because the diagnosis was wrong. (It was a fungus.) Perhaps the condition is inherently unresponsive (like knee psoriasis). Sometimes, the patient didn’t use the cream.

Then we break down that third category. Why would a patient not use the cream? Reasons include:

• The tube was too small (15 g for a full-body rash).

• The steroid did work, but the patient thought it didn’t because the eczema came back. (Eczema comes back.)

• The patient was afraid of steroids. ("I heard they thin your skin.")

I end our session by noting that this third group (the patient didn’t use the cream) is a) intellectually uninteresting; and b) the reason behind most cases were "the steroid didn’t work." By contrast, using the wrong steroid – as defined by the fine-grained distinctions on steroid potency tables – is rarely the difference between success and failure.

I give students a list of four generics, from weak to strong, and advise them not to clutter up their brains with any others. (Since most of them are headed for primary care, those four will be plenty, freeing brain space for board memorization.)

Ever since medical school, which is a rather long time ago by now, I’ve wondered why some things are taught and others left out. More particularly, why are some kinds of facts thought to be important (the ones you can quantify or put numbers next to, for instance) and others are too squishy to mention (such as knowing what the patient thinks about the treatment)?

After all, knowing what a patient thinks about what a treatment does – how it might harm them, and what a treatment "working" really means – has a lot to do with whether the treatment is used properly, or used at all. Why isn’t that important? Because you can’t put it into a table laced with decimal points and percentages?

The tendency to reduce everything to what you can measure has been around for a long time but seems to be getting worse. I read the other day about something called the Human Connectome Project, an effort to produce data to help answer the central question, "How do differences between you and me and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, and our experiences?"

I am not the first to wonder whether functional MRIs, with those gaily colored snapshots of the brain in action, really tell us more about how the brain works than does talking with the people who own those brains. The assumption seems to be that pictures of brain circuits are "real," whereas mere talk is mush, not the stuff of science, whose fruits we physicians are supposed to apply. I am wired, therefore I am.

Suppose a patient thinks that topical steroids thin the skin? Suppose she expects your eczema cream to make the rash go away once and for all, and when it comes back, she takes that as proof that it "didn’t work" and stops using it because it’s clearly worthless? Would those opinions show up on a color photo of her amygdala?

Can my patients be the only ones whose opinions about health and disease matter more, and more often, than do the tabulated measures of clinical efficacy?

You know, the real stuff you have to memorize and document, to get in and to get by.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Students who spend a month with me always want a session on topical steroids, that great undiscovered world they have to know but dread to explore. They’ve all seen those tables of steroid potency based on the rabbit-ear bioassay. These run to long columns (or several pages) of small print ordering the steroid universe from the aristocracy of Class 1 ("Supernovacort" 0.015%) down through the midrange ("Mediocricort" 0.026% ointment is Class 2, while Mediocricort 0.026% cream is only Class 3), down to the humble "Trivialicort" 32%, which on a good day is just a measly Class 6. All those multisyllabic names and numbers and classes bewilder and intimidate the poor kids. Even their earnest medical-student memorization skills leave them in despair of mastering all this stuff.

I ask them to ponder a mini-scenario: Your patient was given a topical steroid cream. He says it didn’t work. List all possible explanations.

The next day we discuss their answers. Most students manage to come up with several types of reasons. Maybe the steroid didn’t work because the diagnosis was wrong. (It was a fungus.) Perhaps the condition is inherently unresponsive (like knee psoriasis). Sometimes, the patient didn’t use the cream.

Then we break down that third category. Why would a patient not use the cream? Reasons include:

• The tube was too small (15 g for a full-body rash).

• The steroid did work, but the patient thought it didn’t because the eczema came back. (Eczema comes back.)

• The patient was afraid of steroids. ("I heard they thin your skin.")

I end our session by noting that this third group (the patient didn’t use the cream) is a) intellectually uninteresting; and b) the reason behind most cases were "the steroid didn’t work." By contrast, using the wrong steroid – as defined by the fine-grained distinctions on steroid potency tables – is rarely the difference between success and failure.

I give students a list of four generics, from weak to strong, and advise them not to clutter up their brains with any others. (Since most of them are headed for primary care, those four will be plenty, freeing brain space for board memorization.)

Ever since medical school, which is a rather long time ago by now, I’ve wondered why some things are taught and others left out. More particularly, why are some kinds of facts thought to be important (the ones you can quantify or put numbers next to, for instance) and others are too squishy to mention (such as knowing what the patient thinks about the treatment)?

After all, knowing what a patient thinks about what a treatment does – how it might harm them, and what a treatment "working" really means – has a lot to do with whether the treatment is used properly, or used at all. Why isn’t that important? Because you can’t put it into a table laced with decimal points and percentages?

The tendency to reduce everything to what you can measure has been around for a long time but seems to be getting worse. I read the other day about something called the Human Connectome Project, an effort to produce data to help answer the central question, "How do differences between you and me and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, and our experiences?"

I am not the first to wonder whether functional MRIs, with those gaily colored snapshots of the brain in action, really tell us more about how the brain works than does talking with the people who own those brains. The assumption seems to be that pictures of brain circuits are "real," whereas mere talk is mush, not the stuff of science, whose fruits we physicians are supposed to apply. I am wired, therefore I am.

Suppose a patient thinks that topical steroids thin the skin? Suppose she expects your eczema cream to make the rash go away once and for all, and when it comes back, she takes that as proof that it "didn’t work" and stops using it because it’s clearly worthless? Would those opinions show up on a color photo of her amygdala?

Can my patients be the only ones whose opinions about health and disease matter more, and more often, than do the tabulated measures of clinical efficacy?

You know, the real stuff you have to memorize and document, to get in and to get by.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

Students who spend a month with me always want a session on topical steroids, that great undiscovered world they have to know but dread to explore. They’ve all seen those tables of steroid potency based on the rabbit-ear bioassay. These run to long columns (or several pages) of small print ordering the steroid universe from the aristocracy of Class 1 ("Supernovacort" 0.015%) down through the midrange ("Mediocricort" 0.026% ointment is Class 2, while Mediocricort 0.026% cream is only Class 3), down to the humble "Trivialicort" 32%, which on a good day is just a measly Class 6. All those multisyllabic names and numbers and classes bewilder and intimidate the poor kids. Even their earnest medical-student memorization skills leave them in despair of mastering all this stuff.

I ask them to ponder a mini-scenario: Your patient was given a topical steroid cream. He says it didn’t work. List all possible explanations.

The next day we discuss their answers. Most students manage to come up with several types of reasons. Maybe the steroid didn’t work because the diagnosis was wrong. (It was a fungus.) Perhaps the condition is inherently unresponsive (like knee psoriasis). Sometimes, the patient didn’t use the cream.

Then we break down that third category. Why would a patient not use the cream? Reasons include:

• The tube was too small (15 g for a full-body rash).

• The steroid did work, but the patient thought it didn’t because the eczema came back. (Eczema comes back.)

• The patient was afraid of steroids. ("I heard they thin your skin.")

I end our session by noting that this third group (the patient didn’t use the cream) is a) intellectually uninteresting; and b) the reason behind most cases were "the steroid didn’t work." By contrast, using the wrong steroid – as defined by the fine-grained distinctions on steroid potency tables – is rarely the difference between success and failure.

I give students a list of four generics, from weak to strong, and advise them not to clutter up their brains with any others. (Since most of them are headed for primary care, those four will be plenty, freeing brain space for board memorization.)

Ever since medical school, which is a rather long time ago by now, I’ve wondered why some things are taught and others left out. More particularly, why are some kinds of facts thought to be important (the ones you can quantify or put numbers next to, for instance) and others are too squishy to mention (such as knowing what the patient thinks about the treatment)?

After all, knowing what a patient thinks about what a treatment does – how it might harm them, and what a treatment "working" really means – has a lot to do with whether the treatment is used properly, or used at all. Why isn’t that important? Because you can’t put it into a table laced with decimal points and percentages?

The tendency to reduce everything to what you can measure has been around for a long time but seems to be getting worse. I read the other day about something called the Human Connectome Project, an effort to produce data to help answer the central question, "How do differences between you and me and how our brains are wired up, relate to differences in our behaviors, our thoughts, our emotions, our feelings, and our experiences?"

I am not the first to wonder whether functional MRIs, with those gaily colored snapshots of the brain in action, really tell us more about how the brain works than does talking with the people who own those brains. The assumption seems to be that pictures of brain circuits are "real," whereas mere talk is mush, not the stuff of science, whose fruits we physicians are supposed to apply. I am wired, therefore I am.

Suppose a patient thinks that topical steroids thin the skin? Suppose she expects your eczema cream to make the rash go away once and for all, and when it comes back, she takes that as proof that it "didn’t work" and stops using it because it’s clearly worthless? Would those opinions show up on a color photo of her amygdala?

Can my patients be the only ones whose opinions about health and disease matter more, and more often, than do the tabulated measures of clinical efficacy?

You know, the real stuff you have to memorize and document, to get in and to get by.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since 1997.

My object all sublime

I shall achieve in time –

To let the punishment fit the crime –

The punishment fit the crime.

–The Mikado

Gilbert and Sullivan

The Mikado’s ambition to give back in a jocular, but apt, way to the subjects who annoyed him is well known. Although I am no Mikado and don’t give back to anybody, aptly or otherwise, I have to admit that the impulse to do so does cross my mind. Maybe it crosses yours, too. Here are some people I sometimes meet. You might recognize them, and perhaps approve some of my suggested just deserts; punishments that fit the crime (PTFTC).

• The imaginary voice mail. "Call John Doe back right away," reads the message. "Use this number."

"You have reached 617-555-1234. This voice-mailbox has not yet been set up and cannot accept calls. Goodbye."

PTFTC: New outgoing message: "Dr. Rockoff is not actually a dermatologist yet. He will get back to you as soon as he becomes one."

• Playing with a full box. "You have reached 617-555-4321. This mailbox is full and cannot accept messages. Goodbye."

PTFTC: Outgoing message: "You have reached the doctor’s office. The doctor has filled his monthly quota of advice giving. Please call back next month, preferably before the 9th."

• Never mind who this is. "Doctor, please call me back right away. My itch is terrible and the medicine you prescribed doesn’t work at all." Click.

PTFTC: Outgoing message: Heavy breathing for 30 seconds. (Has to be for everyone, since we don’t know the number to call.)

• Mumbles. "Doctor, zy... Zyglub ... really need frtunsn mnidioos ... You ... to dhrsrsrs ... 617-96dlubgx ... Again, the number is zigd ... 52879 ... cloy."

PTFTC: Outgoing message. "Hello, Zyg! Glub Dr. Roc ... Bfflp! Yucca grapetz! ... Brgl nice day!"

• The anonymous e-mailer. "Hi, Doc! That cream is great! Can you call more into my pharmacy? Thanks! Skip ([email protected].)

PTFTC: Return e-mail: "Hey, Skip! Take care on that skateboard! Could I have your name? Thanks!"

• The mailed-scrip requester. "Please mail a prescription to Mr. Bean’s house," says the message. "It can’t be called or faxed in. It has to be mailed, with a 90-day supply and three refills."

PTFTC: "Dear Mr. Bean, Kindly send a detailed prescription request typed on an Underwood manual manufactured no later than 1936. Please include a stamped, self-addressed envelope with correct postage. Thank you."

• The walk-in scrip requester. "Doctor," says my front-desk person, catching me in the hall between patients. "Dimitriy is in the waiting room. He says he needs you to write out refills for the three medicines you gave him – the one for the scalp, the one for the body, and the one for the other part that he doesn’t want to tell me about. He says he’ll wait."

PTFTC: "Tell Dimitriy that I need to review his record in detail. I should be done first thing tomorrow morning."

• The highly-detailed-scrip requester. "Doctor, my insurer requires that my prescription be written in a specific way: ‘SuperDerm cream, six 45-gram tunes for a 90-day supply, apply twice a day, morning and night, substitution mandated on penalty of reporting to the Highest Authorities.’ After you’re done with that, I’ll instruct you on the correct way to write my three other prescriptions."

PTFTC: "Here are four blank prescription forms. Please fill them out exactly as your insurer requires. I will return in 21 minutes to review and sign them."

Turnabout is of course fair play. I am sure that many patients, mine and yours, could readily generate lists of our infractions along with appropriate penalties. For instance:

• The doctor kept me waiting so long that I got a parking ticket.

• He called in the solution when I specifically asked for the cream.

• I rearranged my whole schedule and hired a babysitter to keep my appointment, and then her office called the day before and canceled it.

To show my even-handedness, I have set up a Let-the-Punishment-Fit-the-Crime hotline for any patients reading this article. To take these calls, I have rented a special office just outside Fargo, North Dakota, at 701-555-6789, although I’m rarely there.

Oh yes, the voice mail hasn’t been set up yet.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

My object all sublime

I shall achieve in time –

To let the punishment fit the crime –

The punishment fit the crime.

–The Mikado

Gilbert and Sullivan

The Mikado’s ambition to give back in a jocular, but apt, way to the subjects who annoyed him is well known. Although I am no Mikado and don’t give back to anybody, aptly or otherwise, I have to admit that the impulse to do so does cross my mind. Maybe it crosses yours, too. Here are some people I sometimes meet. You might recognize them, and perhaps approve some of my suggested just deserts; punishments that fit the crime (PTFTC).

• The imaginary voice mail. "Call John Doe back right away," reads the message. "Use this number."

"You have reached 617-555-1234. This voice-mailbox has not yet been set up and cannot accept calls. Goodbye."

PTFTC: New outgoing message: "Dr. Rockoff is not actually a dermatologist yet. He will get back to you as soon as he becomes one."

• Playing with a full box. "You have reached 617-555-4321. This mailbox is full and cannot accept messages. Goodbye."

PTFTC: Outgoing message: "You have reached the doctor’s office. The doctor has filled his monthly quota of advice giving. Please call back next month, preferably before the 9th."

• Never mind who this is. "Doctor, please call me back right away. My itch is terrible and the medicine you prescribed doesn’t work at all." Click.

PTFTC: Outgoing message: Heavy breathing for 30 seconds. (Has to be for everyone, since we don’t know the number to call.)

• Mumbles. "Doctor, zy... Zyglub ... really need frtunsn mnidioos ... You ... to dhrsrsrs ... 617-96dlubgx ... Again, the number is zigd ... 52879 ... cloy."

PTFTC: Outgoing message. "Hello, Zyg! Glub Dr. Roc ... Bfflp! Yucca grapetz! ... Brgl nice day!"

• The anonymous e-mailer. "Hi, Doc! That cream is great! Can you call more into my pharmacy? Thanks! Skip ([email protected].)

PTFTC: Return e-mail: "Hey, Skip! Take care on that skateboard! Could I have your name? Thanks!"

• The mailed-scrip requester. "Please mail a prescription to Mr. Bean’s house," says the message. "It can’t be called or faxed in. It has to be mailed, with a 90-day supply and three refills."

PTFTC: "Dear Mr. Bean, Kindly send a detailed prescription request typed on an Underwood manual manufactured no later than 1936. Please include a stamped, self-addressed envelope with correct postage. Thank you."

• The walk-in scrip requester. "Doctor," says my front-desk person, catching me in the hall between patients. "Dimitriy is in the waiting room. He says he needs you to write out refills for the three medicines you gave him – the one for the scalp, the one for the body, and the one for the other part that he doesn’t want to tell me about. He says he’ll wait."

PTFTC: "Tell Dimitriy that I need to review his record in detail. I should be done first thing tomorrow morning."

• The highly-detailed-scrip requester. "Doctor, my insurer requires that my prescription be written in a specific way: ‘SuperDerm cream, six 45-gram tunes for a 90-day supply, apply twice a day, morning and night, substitution mandated on penalty of reporting to the Highest Authorities.’ After you’re done with that, I’ll instruct you on the correct way to write my three other prescriptions."

PTFTC: "Here are four blank prescription forms. Please fill them out exactly as your insurer requires. I will return in 21 minutes to review and sign them."

Turnabout is of course fair play. I am sure that many patients, mine and yours, could readily generate lists of our infractions along with appropriate penalties. For instance:

• The doctor kept me waiting so long that I got a parking ticket.

• He called in the solution when I specifically asked for the cream.

• I rearranged my whole schedule and hired a babysitter to keep my appointment, and then her office called the day before and canceled it.

To show my even-handedness, I have set up a Let-the-Punishment-Fit-the-Crime hotline for any patients reading this article. To take these calls, I have rented a special office just outside Fargo, North Dakota, at 701-555-6789, although I’m rarely there.

Oh yes, the voice mail hasn’t been set up yet.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

My object all sublime

I shall achieve in time –

To let the punishment fit the crime –

The punishment fit the crime.

–The Mikado

Gilbert and Sullivan

The Mikado’s ambition to give back in a jocular, but apt, way to the subjects who annoyed him is well known. Although I am no Mikado and don’t give back to anybody, aptly or otherwise, I have to admit that the impulse to do so does cross my mind. Maybe it crosses yours, too. Here are some people I sometimes meet. You might recognize them, and perhaps approve some of my suggested just deserts; punishments that fit the crime (PTFTC).

• The imaginary voice mail. "Call John Doe back right away," reads the message. "Use this number."

"You have reached 617-555-1234. This voice-mailbox has not yet been set up and cannot accept calls. Goodbye."

PTFTC: New outgoing message: "Dr. Rockoff is not actually a dermatologist yet. He will get back to you as soon as he becomes one."

• Playing with a full box. "You have reached 617-555-4321. This mailbox is full and cannot accept messages. Goodbye."

PTFTC: Outgoing message: "You have reached the doctor’s office. The doctor has filled his monthly quota of advice giving. Please call back next month, preferably before the 9th."

• Never mind who this is. "Doctor, please call me back right away. My itch is terrible and the medicine you prescribed doesn’t work at all." Click.

PTFTC: Outgoing message: Heavy breathing for 30 seconds. (Has to be for everyone, since we don’t know the number to call.)

• Mumbles. "Doctor, zy... Zyglub ... really need frtunsn mnidioos ... You ... to dhrsrsrs ... 617-96dlubgx ... Again, the number is zigd ... 52879 ... cloy."

PTFTC: Outgoing message. "Hello, Zyg! Glub Dr. Roc ... Bfflp! Yucca grapetz! ... Brgl nice day!"

• The anonymous e-mailer. "Hi, Doc! That cream is great! Can you call more into my pharmacy? Thanks! Skip ([email protected].)

PTFTC: Return e-mail: "Hey, Skip! Take care on that skateboard! Could I have your name? Thanks!"

• The mailed-scrip requester. "Please mail a prescription to Mr. Bean’s house," says the message. "It can’t be called or faxed in. It has to be mailed, with a 90-day supply and three refills."

PTFTC: "Dear Mr. Bean, Kindly send a detailed prescription request typed on an Underwood manual manufactured no later than 1936. Please include a stamped, self-addressed envelope with correct postage. Thank you."

• The walk-in scrip requester. "Doctor," says my front-desk person, catching me in the hall between patients. "Dimitriy is in the waiting room. He says he needs you to write out refills for the three medicines you gave him – the one for the scalp, the one for the body, and the one for the other part that he doesn’t want to tell me about. He says he’ll wait."

PTFTC: "Tell Dimitriy that I need to review his record in detail. I should be done first thing tomorrow morning."

• The highly-detailed-scrip requester. "Doctor, my insurer requires that my prescription be written in a specific way: ‘SuperDerm cream, six 45-gram tunes for a 90-day supply, apply twice a day, morning and night, substitution mandated on penalty of reporting to the Highest Authorities.’ After you’re done with that, I’ll instruct you on the correct way to write my three other prescriptions."

PTFTC: "Here are four blank prescription forms. Please fill them out exactly as your insurer requires. I will return in 21 minutes to review and sign them."

Turnabout is of course fair play. I am sure that many patients, mine and yours, could readily generate lists of our infractions along with appropriate penalties. For instance:

• The doctor kept me waiting so long that I got a parking ticket.

• He called in the solution when I specifically asked for the cream.

• I rearranged my whole schedule and hired a babysitter to keep my appointment, and then her office called the day before and canceled it.

To show my even-handedness, I have set up a Let-the-Punishment-Fit-the-Crime hotline for any patients reading this article. To take these calls, I have rented a special office just outside Fargo, North Dakota, at 701-555-6789, although I’m rarely there.

Oh yes, the voice mail hasn’t been set up yet.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

The scenario was familiar. Henry looked peeved. Mary looked anxious. Henry spoke first.

"This spot on my nose has been there for months," he said. "I’m concerned because we’ll be in the sun in Aruba next week."

I examined Henry. "It’s not skin cancer," I said. "Just leave it alone, and it’ll be fine.

"Of course," I went on, "you’ll want to take sensible sun precautions while you’re on vacation, a hat, sunscreen, and so forth." That’s when Mary spoke up.

"You know, Doctor," she said, "Henry does not take sensible sun precautions."

"Yes I do!" Henry objected. "At 10 every morning I leave the beach ..." Mary interrupted him. "He abuses the sun, even though I remind him every day." You could tell by Henry’s hangdog expression that "every day" was no exaggeration.

In its many forms, the eternal battle of the sexes has been examined in countless books, plays, movies, and sitcoms. Gender stereotypes don’t tell the whole story, but without some truth they wouldn’t become stereotypes. There is no getting around the fact that men and women often have their own ways of looking at the world. One part of the world they see differently is health in general and skin health in particular.

I don’t know what life is like on other planets, but if it’s true that men are from Mars and women are from Venus, then it follows that:

• People on Venus follow instructions, eat right, and take care of things so they don’t get out of control. People on Mars can’t be bothered with stuff like that.

• People on Venus wash regularly and use good products. On Mars they don’t much care.

• Venusians moisturize and use sunscreen. Not Martians.

Mini-dramas like that of Henry and Mary play themselves out in our offices all the time. Women take health maintenance more seriously than men do (or than men like to pretend they do.) Proper face washing (in adolescents), regular mole checks (in adults), and careful sun care (especially among the older set) are common flashpoints of gender disagreement. By and large, women feel responsible to make sure men do the right thing, while men just want to be left alone. "I’m only here because..." says the man, but I cut him off. I know why he’s here. It’s just a question of which woman got him there. Real men, you see, don’t ask directions or visit doctors.

One of the right things that women feel obliged to encourage is moisturizing. Men are functional: We shop when we need something and we moisturize when we feel dry. Women think you should moisturize every day, regardless, to make skin healthier and ward off aging.

Maybe so, maybe not, but we men as a group really dislike the feel of lotions on our skin and resist applying them. We find the sensation unpleasant, and anyhow don’t get why we should bother in the first place. Women in turn can’t figure why men should be so cussedly defiant about doing what seems to them not just worthwhile but delightful.

Men, accompanied by women or sent in by them against their better judgment, often make a great show of being put upon. They shrug, roll their eyes, and look irritated, much as they did when they were 8 years old and their mother said, "Tell him, Doctor. Tell him to eat his vegetables. Tell him to wash his face." Now that he’s grown up, her plea is more likely to be, "Tell him, Doctor. Tell him he has to get his spots checked and put sunscreen on every day. Maybe he’ll listen to you. I tell him all the time but he never listens to me." When that happens, I try to split the difference when I can and let both parties save face. After all, they have to live with each other, not with me.

Besides, men’s little secret is that we expect the women in our lives to take care of us and make sure we do the right things that we can’t be bothered to do for ourselves. For many couples, that’s the unspoken deal. We men know it, but we keep it quiet, even from ourselves. Shh, don’t tell anybody ...

Besides, we don’t even have to ask directions anymore. We’ve got GPS!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002. Skin & Allergy News is a publication of Frontline Medical Communications.

The scenario was familiar. Henry looked peeved. Mary looked anxious. Henry spoke first.

"This spot on my nose has been there for months," he said. "I’m concerned because we’ll be in the sun in Aruba next week."

I examined Henry. "It’s not skin cancer," I said. "Just leave it alone, and it’ll be fine.

"Of course," I went on, "you’ll want to take sensible sun precautions while you’re on vacation, a hat, sunscreen, and so forth." That’s when Mary spoke up.

"You know, Doctor," she said, "Henry does not take sensible sun precautions."

"Yes I do!" Henry objected. "At 10 every morning I leave the beach ..." Mary interrupted him. "He abuses the sun, even though I remind him every day." You could tell by Henry’s hangdog expression that "every day" was no exaggeration.

In its many forms, the eternal battle of the sexes has been examined in countless books, plays, movies, and sitcoms. Gender stereotypes don’t tell the whole story, but without some truth they wouldn’t become stereotypes. There is no getting around the fact that men and women often have their own ways of looking at the world. One part of the world they see differently is health in general and skin health in particular.

I don’t know what life is like on other planets, but if it’s true that men are from Mars and women are from Venus, then it follows that:

• People on Venus follow instructions, eat right, and take care of things so they don’t get out of control. People on Mars can’t be bothered with stuff like that.

• People on Venus wash regularly and use good products. On Mars they don’t much care.

• Venusians moisturize and use sunscreen. Not Martians.

Mini-dramas like that of Henry and Mary play themselves out in our offices all the time. Women take health maintenance more seriously than men do (or than men like to pretend they do.) Proper face washing (in adolescents), regular mole checks (in adults), and careful sun care (especially among the older set) are common flashpoints of gender disagreement. By and large, women feel responsible to make sure men do the right thing, while men just want to be left alone. "I’m only here because..." says the man, but I cut him off. I know why he’s here. It’s just a question of which woman got him there. Real men, you see, don’t ask directions or visit doctors.

One of the right things that women feel obliged to encourage is moisturizing. Men are functional: We shop when we need something and we moisturize when we feel dry. Women think you should moisturize every day, regardless, to make skin healthier and ward off aging.

Maybe so, maybe not, but we men as a group really dislike the feel of lotions on our skin and resist applying them. We find the sensation unpleasant, and anyhow don’t get why we should bother in the first place. Women in turn can’t figure why men should be so cussedly defiant about doing what seems to them not just worthwhile but delightful.

Men, accompanied by women or sent in by them against their better judgment, often make a great show of being put upon. They shrug, roll their eyes, and look irritated, much as they did when they were 8 years old and their mother said, "Tell him, Doctor. Tell him to eat his vegetables. Tell him to wash his face." Now that he’s grown up, her plea is more likely to be, "Tell him, Doctor. Tell him he has to get his spots checked and put sunscreen on every day. Maybe he’ll listen to you. I tell him all the time but he never listens to me." When that happens, I try to split the difference when I can and let both parties save face. After all, they have to live with each other, not with me.

Besides, men’s little secret is that we expect the women in our lives to take care of us and make sure we do the right things that we can’t be bothered to do for ourselves. For many couples, that’s the unspoken deal. We men know it, but we keep it quiet, even from ourselves. Shh, don’t tell anybody ...

Besides, we don’t even have to ask directions anymore. We’ve got GPS!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002. Skin & Allergy News is a publication of Frontline Medical Communications.

The scenario was familiar. Henry looked peeved. Mary looked anxious. Henry spoke first.

"This spot on my nose has been there for months," he said. "I’m concerned because we’ll be in the sun in Aruba next week."

I examined Henry. "It’s not skin cancer," I said. "Just leave it alone, and it’ll be fine.

"Of course," I went on, "you’ll want to take sensible sun precautions while you’re on vacation, a hat, sunscreen, and so forth." That’s when Mary spoke up.

"You know, Doctor," she said, "Henry does not take sensible sun precautions."

"Yes I do!" Henry objected. "At 10 every morning I leave the beach ..." Mary interrupted him. "He abuses the sun, even though I remind him every day." You could tell by Henry’s hangdog expression that "every day" was no exaggeration.

In its many forms, the eternal battle of the sexes has been examined in countless books, plays, movies, and sitcoms. Gender stereotypes don’t tell the whole story, but without some truth they wouldn’t become stereotypes. There is no getting around the fact that men and women often have their own ways of looking at the world. One part of the world they see differently is health in general and skin health in particular.

I don’t know what life is like on other planets, but if it’s true that men are from Mars and women are from Venus, then it follows that:

• People on Venus follow instructions, eat right, and take care of things so they don’t get out of control. People on Mars can’t be bothered with stuff like that.

• People on Venus wash regularly and use good products. On Mars they don’t much care.

• Venusians moisturize and use sunscreen. Not Martians.

Mini-dramas like that of Henry and Mary play themselves out in our offices all the time. Women take health maintenance more seriously than men do (or than men like to pretend they do.) Proper face washing (in adolescents), regular mole checks (in adults), and careful sun care (especially among the older set) are common flashpoints of gender disagreement. By and large, women feel responsible to make sure men do the right thing, while men just want to be left alone. "I’m only here because..." says the man, but I cut him off. I know why he’s here. It’s just a question of which woman got him there. Real men, you see, don’t ask directions or visit doctors.

One of the right things that women feel obliged to encourage is moisturizing. Men are functional: We shop when we need something and we moisturize when we feel dry. Women think you should moisturize every day, regardless, to make skin healthier and ward off aging.

Maybe so, maybe not, but we men as a group really dislike the feel of lotions on our skin and resist applying them. We find the sensation unpleasant, and anyhow don’t get why we should bother in the first place. Women in turn can’t figure why men should be so cussedly defiant about doing what seems to them not just worthwhile but delightful.

Men, accompanied by women or sent in by them against their better judgment, often make a great show of being put upon. They shrug, roll their eyes, and look irritated, much as they did when they were 8 years old and their mother said, "Tell him, Doctor. Tell him to eat his vegetables. Tell him to wash his face." Now that he’s grown up, her plea is more likely to be, "Tell him, Doctor. Tell him he has to get his spots checked and put sunscreen on every day. Maybe he’ll listen to you. I tell him all the time but he never listens to me." When that happens, I try to split the difference when I can and let both parties save face. After all, they have to live with each other, not with me.

Besides, men’s little secret is that we expect the women in our lives to take care of us and make sure we do the right things that we can’t be bothered to do for ourselves. For many couples, that’s the unspoken deal. We men know it, but we keep it quiet, even from ourselves. Shh, don’t tell anybody ...

Besides, we don’t even have to ask directions anymore. We’ve got GPS!

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002. Skin & Allergy News is a publication of Frontline Medical Communications.

If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.

They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.

Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.

What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.

Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.

I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.

We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.

"How’s your eczema been?" I asked.

"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."

Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.

Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.

I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.

Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "

I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.

"Went away," he said. "No problems anymore." I’d never have guessed.

What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.

So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.

There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.

Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.

Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.

They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.

Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.

What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.

Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.

I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.

We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.

"How’s your eczema been?" I asked.

"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."

Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.

Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.

I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.

Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "

I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.

"Went away," he said. "No problems anymore." I’d never have guessed.

What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.

So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.

There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.

Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.

Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

If you can believe it, I once read a witty article about hair transplants. The authors suggested that the reporting of results should show follow-ups much longer than 6 or 12 months, since hair loss keeps on happening after transplants. What looks fine at 1 year may not look so good 10 years later.

They labeled one figure in their paper as follows: "True long-term follow-up." It was a photo of a tombstone.

Neither medical school nor residency training fosters the long view. You see a patient during a hospitalization for an acute illness. Case presentation focuses on diagnosis, pathogenesis, and treatment for the few days he or she is on the ward. You may follow the patient for at most a few months, or a year after discharge. Those discussing the case might note a prognosis in passing, but don’t give much sense of what is likely to happen to the patient over the course of years, let alone decades.

What actually happens, long after the patient goes home or the residency ends, varies much more than may seem plausible based on the snapshot you get during an acute episode.

Medical practice in the community, by contrast, is a long-haul affair. What you see when you follow patients for years can be quite unexpected.

I think of John, for instance. As a teenager, he had many bouts of widespread and debilitating atopic dermatitis. Topical therapy often failed to make a dent, leading to courses of prednisone that were followed at once by severe recurrences. Had someone asked me at the time, I would have predicted for John a life of miserable itch, and morbidity from systemic treatment.

We lost touch when John went off to college. He returned 15 years later, now all grown up, with a wife and family. He wanted to show me a mole.

"How’s your eczema been?" I asked.

"It’s hardly bothered me much the last 10 years," John said. "I just use your cream now and then."

Then there was Samantha, who developed extensive acne at age 8. With such an early start, she seemed headed for a rough adolescence. Yet her face cleared and the acne never recurred.

Felicia, on the other hand, showed up at age 32 with severe, cystic acne. She insisted this had started only 6 months before. "I never had it when I was younger," she said.

I was skeptical, and asked her to show me photos from before the outbreak. Sure enough, a picture taken a year earlier showed a completely unblemished complexion.

Then there was Caroline, who at age 9 had severe psoriasis that was hard to control. Because unpleasant scaling affected her forehead and face, classmates often made comments. I’ll never forget her answer when I asked Caroline how she responded to these remarks. She said, "I tell them, ‘At least my face they can fix!’ "

I lost track of Caroline too. (Patients call more when they’re bothered than when they’re doing well.) Her father visited me years later for issues of his own. "How is Caroline’s psoriasis?" I asked him.

"Went away," he said. "No problems anymore." I’d never have guessed.

What about patients with skin cancer? If someone gets a basal cell carcinoma at age 21 years, you would expect him to be at serious risk for getting many more and want to follow him closely.

So would I, and of course I do. But as the years roll by, many of the patients I’ve seen who fall into this category never get another skin cancer, of whatever kind.

There have been plenty of times when my own track record of anticipating the course of disease has been no better than those of the experts on sports talk radio who predict the outcome of professional football games. By the end of the season, they don’t look so expert, but they go on predicting anyway.

Predictions have consequences. Rheumatologists who prescribe biologic agents have been sending patients for skin checks "because I have a high risk of skin cancer," as do surgeons for people from whom they’ve removed a mildly dysplastic nevus. Skin checks are harmless enough, but thinking of yourself as "high risk" is not conducive to equanimity.

Chronic skin issues, like hair loss, go on for a long time. Unexpected things happen, in both directions. When you take the long view, circumspection is best.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

As the date for implementing ICD-10 gets closer, consulting firms send daily offers to help us adapt to the new diagnostic regime. As a service to the profession, Under My Skin will provide periodic updates to save you consulting fees.

In an earlier column, you learned about new codes like injury from burning water skis. We also covered codes for envenomation by Gila monsters, both unintentional and intentional. You should know that these are already available under ICD-9. No need to wait till next year to use them!

ICD-9-CM E905.0: Venomous snakes and lizards causing poisoning and toxic reactions. These include the following: cobra, copperhead snake, coral snake, fer-de-lance snake, Gila monster, krait, mamba, viper, and several others. Do NOT use this code for bites by nonvenomous snakes and lizards. (That may come back to bite you ... Sorry!)

Anyone who can define a fer-de-lance or a krait is gets extra credit (but no extra payment). If you can either identify a mamba, or dance it, good for you!

ICD-10 naturally amplifies this inadequate taxonomy:

• T63.111 – Toxic effect of venom of Gila monster, accidental (unintentional)

• T63.112 – Toxic effect of venom of Gila monster, intentional (self-harm)

• T63.113 – Toxic effect of venom of Gila monster, assault

• T63.114 – Toxic effect of venom of Gila monster, undetermined

Questions: For the new "assault" code, was the Gila monster the assailant or was its owner? Does "undetermined" mean you don’t really know how you got bitten (come on, was that really an accident – weren’t you petting the Gila kind of roughly?) or that you didn’t determine whether it actually was a Gila monster (because it ran away so fast that that it could have been a marmoset).

There are other ICD-9 codes you can already use (right now!) I recently got a 6-page EMR from a referring clinic (you get those, don’t you?) listing one of the patient’s 14 diagnoses as E968.2: Assault by striking by blunt or thrown object.

This opened my eyes to:

• E968.5 – Assault by transport vehicle.

• E968.3 – Assault by hot liquid.

• E968.1 – Assault by pushing from a high place. (Questions: How high? How hot? Transporting what?)

While on the subject of injuries in high places, you might consider:

• E840.1 – Accident by powered aircraft at takeoff or landing.

Again, ICD-10 will be more comprehensive.

Looking at injury from burning water skis, we find:

• V91.07 – Burn due to water-skis on fire.

Within which are:

• V91.07XA ... initial encounter.

• V91.07XD ... subsequent encounter.

• V91.07XS ... sequela.

This is not all! V91.07 has many other subcategories:

• V91.0 – Burn due to watercraft on fire.

• V91.01 – Burn due to passenger ship on fire.

• V91.02 – Burn due to fishing boat on fire.

• V91.05 – Burn due to canoe or kayak on fire.

But wait! There is also V91.1 – Crushed between watercraft and other watercraft or other object due to collision. Within which are:

• V91.10 – Crushed between merchant ship and other watercraft or other object due to collision.

• V91.12 – Crushed between fishing boat and other watercraft or other object due to collision.

• V91.15 – Crushed between canoe or kayak and other watercraft or other object due to collision.

Each of these of course includes subcodes for: initial encounter, subsequent encounter, and sequela. (Conversion hysteria caused by paranoid fear of rampaging kayaks?)

The practical advantages to learning all this extend beyond the office. Suppose you’re fishing in a rowboat on a lazy Sunday afternoon when a kayaker waving a flaming blowtorch careens toward you full tilt and you leap overboard. When the Coast Guard pulls you out, you can shout, "V91.05! V91.15!"

In our next installment, we will take up other subsets of external causes of morbidity, including:

• W20 – struck by thrown, projected, or falling object such as:

• W20.0 – Falling object in cave (initial encounter, subsequent encounter, sequela).

• W20.1 – Struck by object due to collapse of building (ditto).

• W28 – Contact with powered lawn mower.

• W60 – Contact with nonvenomous plant thorns and spines and sharp leaves.

Master these. Future columns will cover injuries caused by forces of nature, injuries caused by supernatural means (such as witchcraft, exorcism), assassination (first episode, second episode, sequela), and acute psychosis caused by marauding ICD-10 consultants.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

As the date for implementing ICD-10 gets closer, consulting firms send daily offers to help us adapt to the new diagnostic regime. As a service to the profession, Under My Skin will provide periodic updates to save you consulting fees.

In an earlier column, you learned about new codes like injury from burning water skis. We also covered codes for envenomation by Gila monsters, both unintentional and intentional. You should know that these are already available under ICD-9. No need to wait till next year to use them!

ICD-9-CM E905.0: Venomous snakes and lizards causing poisoning and toxic reactions. These include the following: cobra, copperhead snake, coral snake, fer-de-lance snake, Gila monster, krait, mamba, viper, and several others. Do NOT use this code for bites by nonvenomous snakes and lizards. (That may come back to bite you ... Sorry!)

Anyone who can define a fer-de-lance or a krait is gets extra credit (but no extra payment). If you can either identify a mamba, or dance it, good for you!

ICD-10 naturally amplifies this inadequate taxonomy:

• T63.111 – Toxic effect of venom of Gila monster, accidental (unintentional)

• T63.112 – Toxic effect of venom of Gila monster, intentional (self-harm)

• T63.113 – Toxic effect of venom of Gila monster, assault

• T63.114 – Toxic effect of venom of Gila monster, undetermined

Questions: For the new "assault" code, was the Gila monster the assailant or was its owner? Does "undetermined" mean you don’t really know how you got bitten (come on, was that really an accident – weren’t you petting the Gila kind of roughly?) or that you didn’t determine whether it actually was a Gila monster (because it ran away so fast that that it could have been a marmoset).

There are other ICD-9 codes you can already use (right now!) I recently got a 6-page EMR from a referring clinic (you get those, don’t you?) listing one of the patient’s 14 diagnoses as E968.2: Assault by striking by blunt or thrown object.

This opened my eyes to:

• E968.5 – Assault by transport vehicle.

• E968.3 – Assault by hot liquid.

• E968.1 – Assault by pushing from a high place. (Questions: How high? How hot? Transporting what?)

While on the subject of injuries in high places, you might consider:

• E840.1 – Accident by powered aircraft at takeoff or landing.

Again, ICD-10 will be more comprehensive.

Looking at injury from burning water skis, we find:

• V91.07 – Burn due to water-skis on fire.

Within which are:

• V91.07XA ... initial encounter.

• V91.07XD ... subsequent encounter.

• V91.07XS ... sequela.

This is not all! V91.07 has many other subcategories:

• V91.0 – Burn due to watercraft on fire.

• V91.01 – Burn due to passenger ship on fire.

• V91.02 – Burn due to fishing boat on fire.

• V91.05 – Burn due to canoe or kayak on fire.

But wait! There is also V91.1 – Crushed between watercraft and other watercraft or other object due to collision. Within which are:

• V91.10 – Crushed between merchant ship and other watercraft or other object due to collision.

• V91.12 – Crushed between fishing boat and other watercraft or other object due to collision.

• V91.15 – Crushed between canoe or kayak and other watercraft or other object due to collision.

Each of these of course includes subcodes for: initial encounter, subsequent encounter, and sequela. (Conversion hysteria caused by paranoid fear of rampaging kayaks?)

The practical advantages to learning all this extend beyond the office. Suppose you’re fishing in a rowboat on a lazy Sunday afternoon when a kayaker waving a flaming blowtorch careens toward you full tilt and you leap overboard. When the Coast Guard pulls you out, you can shout, "V91.05! V91.15!"

In our next installment, we will take up other subsets of external causes of morbidity, including:

• W20 – struck by thrown, projected, or falling object such as:

• W20.0 – Falling object in cave (initial encounter, subsequent encounter, sequela).

• W20.1 – Struck by object due to collapse of building (ditto).

• W28 – Contact with powered lawn mower.

• W60 – Contact with nonvenomous plant thorns and spines and sharp leaves.

Master these. Future columns will cover injuries caused by forces of nature, injuries caused by supernatural means (such as witchcraft, exorcism), assassination (first episode, second episode, sequela), and acute psychosis caused by marauding ICD-10 consultants.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

As the date for implementing ICD-10 gets closer, consulting firms send daily offers to help us adapt to the new diagnostic regime. As a service to the profession, Under My Skin will provide periodic updates to save you consulting fees.

In an earlier column, you learned about new codes like injury from burning water skis. We also covered codes for envenomation by Gila monsters, both unintentional and intentional. You should know that these are already available under ICD-9. No need to wait till next year to use them!

ICD-9-CM E905.0: Venomous snakes and lizards causing poisoning and toxic reactions. These include the following: cobra, copperhead snake, coral snake, fer-de-lance snake, Gila monster, krait, mamba, viper, and several others. Do NOT use this code for bites by nonvenomous snakes and lizards. (That may come back to bite you ... Sorry!)

Anyone who can define a fer-de-lance or a krait is gets extra credit (but no extra payment). If you can either identify a mamba, or dance it, good for you!

ICD-10 naturally amplifies this inadequate taxonomy:

• T63.111 – Toxic effect of venom of Gila monster, accidental (unintentional)

• T63.112 – Toxic effect of venom of Gila monster, intentional (self-harm)

• T63.113 – Toxic effect of venom of Gila monster, assault

• T63.114 – Toxic effect of venom of Gila monster, undetermined

Questions: For the new "assault" code, was the Gila monster the assailant or was its owner? Does "undetermined" mean you don’t really know how you got bitten (come on, was that really an accident – weren’t you petting the Gila kind of roughly?) or that you didn’t determine whether it actually was a Gila monster (because it ran away so fast that that it could have been a marmoset).

There are other ICD-9 codes you can already use (right now!) I recently got a 6-page EMR from a referring clinic (you get those, don’t you?) listing one of the patient’s 14 diagnoses as E968.2: Assault by striking by blunt or thrown object.

This opened my eyes to:

• E968.5 – Assault by transport vehicle.

• E968.3 – Assault by hot liquid.

• E968.1 – Assault by pushing from a high place. (Questions: How high? How hot? Transporting what?)

While on the subject of injuries in high places, you might consider:

• E840.1 – Accident by powered aircraft at takeoff or landing.

Again, ICD-10 will be more comprehensive.

Looking at injury from burning water skis, we find:

• V91.07 – Burn due to water-skis on fire.

Within which are:

• V91.07XA ... initial encounter.

• V91.07XD ... subsequent encounter.

• V91.07XS ... sequela.

This is not all! V91.07 has many other subcategories:

• V91.0 – Burn due to watercraft on fire.

• V91.01 – Burn due to passenger ship on fire.

• V91.02 – Burn due to fishing boat on fire.

• V91.05 – Burn due to canoe or kayak on fire.

But wait! There is also V91.1 – Crushed between watercraft and other watercraft or other object due to collision. Within which are:

• V91.10 – Crushed between merchant ship and other watercraft or other object due to collision.

• V91.12 – Crushed between fishing boat and other watercraft or other object due to collision.

• V91.15 – Crushed between canoe or kayak and other watercraft or other object due to collision.

Each of these of course includes subcodes for: initial encounter, subsequent encounter, and sequela. (Conversion hysteria caused by paranoid fear of rampaging kayaks?)

The practical advantages to learning all this extend beyond the office. Suppose you’re fishing in a rowboat on a lazy Sunday afternoon when a kayaker waving a flaming blowtorch careens toward you full tilt and you leap overboard. When the Coast Guard pulls you out, you can shout, "V91.05! V91.15!"

In our next installment, we will take up other subsets of external causes of morbidity, including:

• W20 – struck by thrown, projected, or falling object such as:

• W20.0 – Falling object in cave (initial encounter, subsequent encounter, sequela).

• W20.1 – Struck by object due to collapse of building (ditto).

• W28 – Contact with powered lawn mower.

• W60 – Contact with nonvenomous plant thorns and spines and sharp leaves.

Master these. Future columns will cover injuries caused by forces of nature, injuries caused by supernatural means (such as witchcraft, exorcism), assassination (first episode, second episode, sequela), and acute psychosis caused by marauding ICD-10 consultants.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years. Dr. Rockoff has contributed to the Under My Skin column in Skin & Allergy News since January 2002.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.

One of my favorite Seinfeld episodes involves Elaine breaking up with a man who likes to mess with the minds of anyone who has the nerve to call it off with him. When Elaine tells him that they’re through, he says to her, "You know, you have a big head."

The rest of the show is devoted to Elaine trying to convince herself that she does not have a big head. In one scene, a cabbie tells the petite Elaine sitting in his back seat, "Please slide down, will you? You’re blocking the window!" And Elaine stands in Central Park in the show’s final scene, a bird flies right into her head as an old man says, "Well, I never saw that before. Looked like the bird just couldn’t get out of the way."

Jerry Seinfeld, who may have OCD-oid tendencies himself, often referred to dermatology in his sketches and showed insight into our patients and our clinical lives. How many people do we see who can’t stop thinking about some part of their appearance, often one we would never guess could be the focus of their attention: a small mole or freckle, a tiny wrinkle, a slight asymmetry in their features? Quite often, these patients become fixated on the feature not because they are "vain" or "narcissistic," and not because they have "body dysmorphic disorder," but just because someone else (and not necessarily somebody they were breaking up with who wanted to get even) pointed it out. From then on, they couldn’t stop thinking about it.

It may have been a doctor. ("That mole, has it been changing?") It may have been a friend. ("You know, the groove on the left side of your nose is deeper than the one on the right.") It may have been a hairdresser – it often is a hairdresser, who can see what you can’t. ("How long has that spot been up here?" Or, "Goodness! I can see right through to your scalp. Are you going bald?!")

Or it could be one of my favorite villains, the magnifying mirror, bane of presbyopic middle-age women. Overcoming presbyopia comes at the price of seeing every nevus as Pike’s Peak and every pore as the Grand Canyon.

In these cases, and many others like them, once the spots or defects are pointed out, people find it all but impossible to stop thinking about them and noticing them every time they look at themselves. If a bird flew by, it would probably slam right into them because it couldn’t get out of the way.

Removing what the patients are fixated on may be unnecessary, risky, or impossible. Advice to "just stop looking" may make sense, but can be unsatisfying or unacceptable.

I had a Seinfeld-esque moment the other day. Inga, thirtyish, came by to discuss acne, and then said, "Can you feel this growth at the end of my eyebrow?" My student and I palpated a small nodule under the outer aspect of her right eyebrow.

"It feels like a cyst," I said. "Probably been there a long time."

"Are you sure?" she asked. "Doesn’t it distort my face?"

We stepped back to a conversational distance. I couldn’t see anything, and neither could the student. "We can’t even see it from here," I told Inga. "What makes you think it distorts your face?"

"I was walking down the street with my mother and sister last week," she said, "and my mother said, "Inga, what is that on your eyebrow? Your whole face looks out of whack! And my sister said, ‘You’d better get that checked out.’"

My student and I stared at her. She was serious.

"Look," I said. "There is something there, but it’s definitely OK, and removing it would be unnecessary and leave a big scar. We honestly have no idea why your mother and sister would say that your face is lopsided when we can’t see anything even when we look for it."

Inga seemed mollified. We had to leave her, as we must leave all patients, to the vagaries of their own family dynamics. I can only hope that Inga doesn’t one day have some cabbie tell her to please lean to the left to keep the taxi from rolling over.

Dr. Rockoff practices dermatology in Brookline, Mass. He is on the clinical faculty at Tufts University School of Medicine, Boston, and has taught senior medical students and other trainees for 30 years.