Alan Rockoff, MD

"My friend took your elective," read the e-mail from Adam, a medical student I didn’t know. "I need one more rotation before I graduate and would love to get some dermatology experience, which I expect I’ll need for Family Medicine. Could you possibly accommodate me?"

Sure, no problem.

The day before he was to start, I e-mailed Adam with the time and place to show up, along with parking suggestions.

"Oh, sorry," came the reply. "I found another elective. Hope this causes no inconvenience."

Thanks, pal.

People, you may have noticed, are not always considerate. This includes patients. Take Irene. Please.

Irene is 28 years old. One of my associates diagnosed pyoderma and gave Irene oral antibiotics. She called Friday afternoon to report headaches and vomiting. Because of a scheduling mix-up, not one colleague – but both of them – thought they were covering and called her back. They each phoned Friday night and left messages on Irene’s home and cell numbers. And again on Saturday, twice each. Ditto on Sunday.

Irene finally did call back. Tuesday. She said she was fine.

Gee, thanks, Irene.

Or consider Zoe. Or more precisely, consider Zoe’s mother, Hildegard. Their family had just returned from Panama, a rain-forest jaunt being just the thing for a 2-year-old. Zoe had returned with a souvenir collection of bizarre, bull’s-eye–shaped plaques all over her face and torso. I had never seen anything like them. Perhaps bites? No one else in the travel party had them.

Because the child did not seem ill, I suggested to Hildegard that we spare Zoe a biopsy and see what happened over the next few days. I photographed the spots and said I would share the pictures with an academic specialist I know. Perhaps Hildegard would send me an e-mail update in 2 days? She would.

My academic friend looked at the photos and also had no idea. And from Hildegard? Radio silence. Was Zoe OK? Was she in an ICU?

I e-mailed Hildegard. No response. Not a good sign. I called and left a message, referring to the e-mail. No response. I wrote the referring pediatrician. No answer there either.

Three weeks later, Hortense, a nurse practitioner from the pediatrician’s office, came in as a patient. With some trepidation, I asked whether she was familiar with Zoe’s condition. She wasn’t. She would check and get back. She didn’t.

But I did, when I called Hortense a couple of days later with her own biopsy results. Had she perhaps checked on Zoe? Oh, right, she had. Zoe was fine. The spots had just gone away. Must have been bites or something.

Think I’ll just up my Valium.

Of course, more prosaic examples of this sort of thing happen all the time. Like the patient who calls for an emergency appointment. He has to come in. Right away.

"9:00 o’clock?" Not convenient. Staff meeting at work.

"2:00 o’clock?" Sorry, can’t make it then.

"5:30?" OK, I’ll be there! Thanks!

Then he doesn’t show. The rash went away. Or he got a better offer. Who knows?

After all these years, I should be used to this behavior by now, but sometimes, annoyance still gets the better of me. There are people – many, actually, and not just in the office – who really need you. Really, really. Their needs are urgent, overwhelming.

Your needs, less so.

There is no point in being cranky about this. We are in the people business, which means taking people as they come. It may mean following through when we worry about the consequences of not doing so, even if the patients themselves seem oblivious. It also means not taking it for granted when people do act with consideration.

Adam’s e-mail that he hoped I was not inconvenienced really steamed me. Then I thought, "I never met this guy, and I never will. He may find this kind of behavior unhelpful in his future professional dealings. But that will be his problem, won’t it?" So I decided not to respond.

Then I changed my mind.

"Inconvenience, no," I e-mailed back. "Inconsideration, for sure."

He apologized again, and I left it at that. There’s no emoticon for a Bronx cheer, anyway.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"My friend took your elective," read the e-mail from Adam, a medical student I didn’t know. "I need one more rotation before I graduate and would love to get some dermatology experience, which I expect I’ll need for Family Medicine. Could you possibly accommodate me?"

Sure, no problem.

The day before he was to start, I e-mailed Adam with the time and place to show up, along with parking suggestions.

"Oh, sorry," came the reply. "I found another elective. Hope this causes no inconvenience."

Thanks, pal.

People, you may have noticed, are not always considerate. This includes patients. Take Irene. Please.

Irene is 28 years old. One of my associates diagnosed pyoderma and gave Irene oral antibiotics. She called Friday afternoon to report headaches and vomiting. Because of a scheduling mix-up, not one colleague – but both of them – thought they were covering and called her back. They each phoned Friday night and left messages on Irene’s home and cell numbers. And again on Saturday, twice each. Ditto on Sunday.

Irene finally did call back. Tuesday. She said she was fine.

Gee, thanks, Irene.

Or consider Zoe. Or more precisely, consider Zoe’s mother, Hildegard. Their family had just returned from Panama, a rain-forest jaunt being just the thing for a 2-year-old. Zoe had returned with a souvenir collection of bizarre, bull’s-eye–shaped plaques all over her face and torso. I had never seen anything like them. Perhaps bites? No one else in the travel party had them.

Because the child did not seem ill, I suggested to Hildegard that we spare Zoe a biopsy and see what happened over the next few days. I photographed the spots and said I would share the pictures with an academic specialist I know. Perhaps Hildegard would send me an e-mail update in 2 days? She would.

My academic friend looked at the photos and also had no idea. And from Hildegard? Radio silence. Was Zoe OK? Was she in an ICU?

I e-mailed Hildegard. No response. Not a good sign. I called and left a message, referring to the e-mail. No response. I wrote the referring pediatrician. No answer there either.

Three weeks later, Hortense, a nurse practitioner from the pediatrician’s office, came in as a patient. With some trepidation, I asked whether she was familiar with Zoe’s condition. She wasn’t. She would check and get back. She didn’t.

But I did, when I called Hortense a couple of days later with her own biopsy results. Had she perhaps checked on Zoe? Oh, right, she had. Zoe was fine. The spots had just gone away. Must have been bites or something.

Think I’ll just up my Valium.

Of course, more prosaic examples of this sort of thing happen all the time. Like the patient who calls for an emergency appointment. He has to come in. Right away.

"9:00 o’clock?" Not convenient. Staff meeting at work.

"2:00 o’clock?" Sorry, can’t make it then.

"5:30?" OK, I’ll be there! Thanks!

Then he doesn’t show. The rash went away. Or he got a better offer. Who knows?

After all these years, I should be used to this behavior by now, but sometimes, annoyance still gets the better of me. There are people – many, actually, and not just in the office – who really need you. Really, really. Their needs are urgent, overwhelming.

Your needs, less so.

There is no point in being cranky about this. We are in the people business, which means taking people as they come. It may mean following through when we worry about the consequences of not doing so, even if the patients themselves seem oblivious. It also means not taking it for granted when people do act with consideration.

Adam’s e-mail that he hoped I was not inconvenienced really steamed me. Then I thought, "I never met this guy, and I never will. He may find this kind of behavior unhelpful in his future professional dealings. But that will be his problem, won’t it?" So I decided not to respond.

Then I changed my mind.

"Inconvenience, no," I e-mailed back. "Inconsideration, for sure."

He apologized again, and I left it at that. There’s no emoticon for a Bronx cheer, anyway.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"My friend took your elective," read the e-mail from Adam, a medical student I didn’t know. "I need one more rotation before I graduate and would love to get some dermatology experience, which I expect I’ll need for Family Medicine. Could you possibly accommodate me?"

Sure, no problem.

The day before he was to start, I e-mailed Adam with the time and place to show up, along with parking suggestions.

"Oh, sorry," came the reply. "I found another elective. Hope this causes no inconvenience."

Thanks, pal.

People, you may have noticed, are not always considerate. This includes patients. Take Irene. Please.

Irene is 28 years old. One of my associates diagnosed pyoderma and gave Irene oral antibiotics. She called Friday afternoon to report headaches and vomiting. Because of a scheduling mix-up, not one colleague – but both of them – thought they were covering and called her back. They each phoned Friday night and left messages on Irene’s home and cell numbers. And again on Saturday, twice each. Ditto on Sunday.

Irene finally did call back. Tuesday. She said she was fine.

Gee, thanks, Irene.

Or consider Zoe. Or more precisely, consider Zoe’s mother, Hildegard. Their family had just returned from Panama, a rain-forest jaunt being just the thing for a 2-year-old. Zoe had returned with a souvenir collection of bizarre, bull’s-eye–shaped plaques all over her face and torso. I had never seen anything like them. Perhaps bites? No one else in the travel party had them.

Because the child did not seem ill, I suggested to Hildegard that we spare Zoe a biopsy and see what happened over the next few days. I photographed the spots and said I would share the pictures with an academic specialist I know. Perhaps Hildegard would send me an e-mail update in 2 days? She would.

My academic friend looked at the photos and also had no idea. And from Hildegard? Radio silence. Was Zoe OK? Was she in an ICU?

I e-mailed Hildegard. No response. Not a good sign. I called and left a message, referring to the e-mail. No response. I wrote the referring pediatrician. No answer there either.

Three weeks later, Hortense, a nurse practitioner from the pediatrician’s office, came in as a patient. With some trepidation, I asked whether she was familiar with Zoe’s condition. She wasn’t. She would check and get back. She didn’t.

But I did, when I called Hortense a couple of days later with her own biopsy results. Had she perhaps checked on Zoe? Oh, right, she had. Zoe was fine. The spots had just gone away. Must have been bites or something.

Think I’ll just up my Valium.

Of course, more prosaic examples of this sort of thing happen all the time. Like the patient who calls for an emergency appointment. He has to come in. Right away.

"9:00 o’clock?" Not convenient. Staff meeting at work.

"2:00 o’clock?" Sorry, can’t make it then.

"5:30?" OK, I’ll be there! Thanks!

Then he doesn’t show. The rash went away. Or he got a better offer. Who knows?

After all these years, I should be used to this behavior by now, but sometimes, annoyance still gets the better of me. There are people – many, actually, and not just in the office – who really need you. Really, really. Their needs are urgent, overwhelming.

Your needs, less so.

There is no point in being cranky about this. We are in the people business, which means taking people as they come. It may mean following through when we worry about the consequences of not doing so, even if the patients themselves seem oblivious. It also means not taking it for granted when people do act with consideration.

Adam’s e-mail that he hoped I was not inconvenienced really steamed me. Then I thought, "I never met this guy, and I never will. He may find this kind of behavior unhelpful in his future professional dealings. But that will be his problem, won’t it?" So I decided not to respond.

Then I changed my mind.

"Inconvenience, no," I e-mailed back. "Inconsideration, for sure."

He apologized again, and I left it at that. There’s no emoticon for a Bronx cheer, anyway.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my children were in school and got head lice, I learned the full metaphorical scope of words like "lousy" and "nit-picking." I also learned that school nurses didn’t give a hoot for my opinions.

Despite my boards in pediatrics and dermatology, my protests against schools’ policies of dragging parents out of work to pick up a kid on whom the nurse found a nit, or thought she did, even after multiple treatments and fine-tooth combing (another nice, real-life metaphor) went unheard.

In vain did I cite policy statements by august professional organizations that no-nit policies were unnecessary. No sir – they find one dead egg case, and Johnny goes home. His parents are obviously irresponsible anyway, not to mention unhygienic. So I gave up, and my children grew up.

What reawakened these memories was my annual visit to Marcie, my eye doctor. "I really like your PA," she said. "Jared saw her when the school nurse sent him home with a rash. Your PA asked him why he was there. ‘The nurse sent me home,’ he said. ‘OK,’ said your PA, ‘now you can go back.’

"They once sent Jared home because of a chalazion," Marcie continued. "I called them up. ‘He’s on tobramycin,’ I told them. ‘And a chalazion isn’t contagious anyway.’ But they didn’t believe me!

"My husband called them. ‘My wife is an eye doctor,’ he said. ‘Oh,’ they said, ‘We didn’t know what kind of doctor she was.’ "

Probably the most egregious example of high-handed school medical behavior I have ever seen played out in my office just last month. The Hightowers brought in 4-year-old Jeffrey with an impetiginized rash. We started cephalexin, pending culture results. When these showed MRSA on Friday afternoon, we called the family to switch Jeffrey to trimethoprim-sulfamethoxazole.

Janice Hightower became very upset. "Should I call the school?" We suggested she use her discretion, because by Monday Jeffrey would no longer be contagious. "But I’m a teacher," she said. "I feel responsible." So she did.

The next day, Jeffrey’s dad, Brian Hightower, came to school to coach baseball (his kids stayed home). During the game, all the parents got text messages informing them: "Someone in the school is infected with MRSA, and school is closed until further notice." He then sat in stunned silence as the other parents commiserated with each other about what happens when their children have to hang around with other kids whose parents are irresponsible, dirty, and a lot of other unpleasant things.

On Monday, Brian Hightower brought Jeffrey’s older brother, Jason, to the office. Jason had no skin lesions at all. "My wife won’t let me go home without antibiotics for him," insisted Brian. We told him there was nothing to treat, and he left. Later, Janice Hightower called. "This is like ‘The Scarlet Letter,’ " she said. "We’ll never be able to show our faces in the community again."

We tried to reassure her (the MRSA culprit’s identity had mercifully not been divulged), but she pressed on. "When he grows up and kisses his first girl," she asked, "will he have to tell her about this?"

Things went downhill from there. Several days and many phone calls later, the Hightowers began to calm down. Jeffrey and Jason returned to school, which had somehow managed to reopen. I have no idea which medical authority authorized the reopening, any more than I know who told them to close it in the first place. Jeffrey hasn’t been sighted kissing any girls yet, other than possibly Aunt Susie.

What this episode says about how people judge and treat others who are ill, not to mention how ancient ideas about disease persist long after they are supposed to have been discarded, doesn’t need to be spelled out. Better to take polite notice and move on.

But it also says quite a lot about the limitations of our professional authority outside the spheres where we’re in charge. In the office, people may or may not listen to us, but at least they act as though they might.

But outside the office, in schools for instance, what we have to say often doesn’t count for much. Or anything.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

Maybe it’s because spring is here and the flowers are blooming. Or it may be because my wife and I are marrying off our daughter this summer. (Why, thank you.) Whatever the reason, I thought I would share some of the ways my married patients met each other. When I ask couples how they got together, they are usually happy to tell me. Even after many years, most of them have no trouble remembering the particular circumstances of their introduction. They smile, and tell me a tale they have probably told many times. (Remember that this is a selected group – these couples are still together!)

Some of the stories are conventional – a mutual friend or family member fixed them up, or they met in high school or college. Nowadays, more and more are technological, though sometimes with a twist. ("I had so many bad experiences on EBliss4Ever.com that I was ready to give up. But then I decided to give it one more try – and got Stanley!") Sometimes, however, people share tales that sound too cute to be true, ones that even Hollywood script committees – lovers of the "cute-meet" – would reject as too schmaltzy and improbable to work in a romantic comedy. And yet, out here in real life, they somehow did.

"I met Lars in a bar," says Bridget. "My friend Susie and I were having a beer, and I decided to stand up and move to another table. Lars is a large person, and he was walking by just when I got up. I turned to my left- – and hit him right in the chest with my glass. The beer splashed all over him and made a real mess. It took a long time to clean up."

"Oh come on. Did that really happen?"

"Absolutely! We were married a year ago."

Then there is Shane Walsh, who tells me not about himself but about his sister. "We’re a close-knit Irish family," he says. "Five boys and a girl. We were very protective of our sister and made sure that the guys she went out with were the right sort. Then she met the man who’s now her husband, and we all agree that he’s terrific. His name is also Walsh."

"In fact, that’s how they met," Shane says. "They were both at a party, when a guy across the room called out, ‘Hey, Walshie!’ "

"Both of them turned around at the same time and saw each other. The rest is history."

The luck of the Irish, I guess.

My last tale concerns an older pair, Gregory and Kate, married 39 years. They remember their first meeting very fondly.

"We both belonged to an apple-picking club," recalls Kate. "That fall weekend the whole group traveled by bus up to Maine. It was raining and miserable. When we got to the farm, the lady handing out the collecting baskets said, ‘You’re not from around here, are you?’ She meant that anybody local would have too much sense to pick apples in the driving rain."

"We were standing near each other under the same tree," said Gregory. "It was just like ..."

"Wait a minute," I interrupt, "you don’t mean ..."

"Yes indeed," says Greg, with a twinkle. "She handed me an apple." Kate laughs in agreement.

There you have it – life imitating Scripture. Although there’s nothing in the Good Book about Adam and Eve hiding under the Tree of Knowledge to keep from getting wet.

Here’s to happy endings, however they start out.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected]. 

Maybe it’s because spring is here and the flowers are blooming. Or it may be because my wife and I are marrying off our daughter this summer. (Why, thank you.) Whatever the reason, I thought I would share some of the ways my married patients met each other. When I ask couples how they got together, they are usually happy to tell me. Even after many years, most of them have no trouble remembering the particular circumstances of their introduction. They smile, and tell me a tale they have probably told many times. (Remember that this is a selected group – these couples are still together!)

Some of the stories are conventional – a mutual friend or family member fixed them up, or they met in high school or college. Nowadays, more and more are technological, though sometimes with a twist. ("I had so many bad experiences on EBliss4Ever.com that I was ready to give up. But then I decided to give it one more try – and got Stanley!") Sometimes, however, people share tales that sound too cute to be true, ones that even Hollywood script committees – lovers of the "cute-meet" – would reject as too schmaltzy and improbable to work in a romantic comedy. And yet, out here in real life, they somehow did.

"I met Lars in a bar," says Bridget. "My friend Susie and I were having a beer, and I decided to stand up and move to another table. Lars is a large person, and he was walking by just when I got up. I turned to my left- – and hit him right in the chest with my glass. The beer splashed all over him and made a real mess. It took a long time to clean up."

"Oh come on. Did that really happen?"

"Absolutely! We were married a year ago."

Then there is Shane Walsh, who tells me not about himself but about his sister. "We’re a close-knit Irish family," he says. "Five boys and a girl. We were very protective of our sister and made sure that the guys she went out with were the right sort. Then she met the man who’s now her husband, and we all agree that he’s terrific. His name is also Walsh."

"In fact, that’s how they met," Shane says. "They were both at a party, when a guy across the room called out, ‘Hey, Walshie!’ "

"Both of them turned around at the same time and saw each other. The rest is history."

The luck of the Irish, I guess.

My last tale concerns an older pair, Gregory and Kate, married 39 years. They remember their first meeting very fondly.

"We both belonged to an apple-picking club," recalls Kate. "That fall weekend the whole group traveled by bus up to Maine. It was raining and miserable. When we got to the farm, the lady handing out the collecting baskets said, ‘You’re not from around here, are you?’ She meant that anybody local would have too much sense to pick apples in the driving rain."

"We were standing near each other under the same tree," said Gregory. "It was just like ..."

"Wait a minute," I interrupt, "you don’t mean ..."

"Yes indeed," says Greg, with a twinkle. "She handed me an apple." Kate laughs in agreement.

There you have it – life imitating Scripture. Although there’s nothing in the Good Book about Adam and Eve hiding under the Tree of Knowledge to keep from getting wet.

Here’s to happy endings, however they start out.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected]. 

Maybe it’s because spring is here and the flowers are blooming. Or it may be because my wife and I are marrying off our daughter this summer. (Why, thank you.) Whatever the reason, I thought I would share some of the ways my married patients met each other. When I ask couples how they got together, they are usually happy to tell me. Even after many years, most of them have no trouble remembering the particular circumstances of their introduction. They smile, and tell me a tale they have probably told many times. (Remember that this is a selected group – these couples are still together!)

Some of the stories are conventional – a mutual friend or family member fixed them up, or they met in high school or college. Nowadays, more and more are technological, though sometimes with a twist. ("I had so many bad experiences on EBliss4Ever.com that I was ready to give up. But then I decided to give it one more try – and got Stanley!") Sometimes, however, people share tales that sound too cute to be true, ones that even Hollywood script committees – lovers of the "cute-meet" – would reject as too schmaltzy and improbable to work in a romantic comedy. And yet, out here in real life, they somehow did.

"I met Lars in a bar," says Bridget. "My friend Susie and I were having a beer, and I decided to stand up and move to another table. Lars is a large person, and he was walking by just when I got up. I turned to my left- – and hit him right in the chest with my glass. The beer splashed all over him and made a real mess. It took a long time to clean up."

"Oh come on. Did that really happen?"

"Absolutely! We were married a year ago."

Then there is Shane Walsh, who tells me not about himself but about his sister. "We’re a close-knit Irish family," he says. "Five boys and a girl. We were very protective of our sister and made sure that the guys she went out with were the right sort. Then she met the man who’s now her husband, and we all agree that he’s terrific. His name is also Walsh."

"In fact, that’s how they met," Shane says. "They were both at a party, when a guy across the room called out, ‘Hey, Walshie!’ "

"Both of them turned around at the same time and saw each other. The rest is history."

The luck of the Irish, I guess.

My last tale concerns an older pair, Gregory and Kate, married 39 years. They remember their first meeting very fondly.

"We both belonged to an apple-picking club," recalls Kate. "That fall weekend the whole group traveled by bus up to Maine. It was raining and miserable. When we got to the farm, the lady handing out the collecting baskets said, ‘You’re not from around here, are you?’ She meant that anybody local would have too much sense to pick apples in the driving rain."

"We were standing near each other under the same tree," said Gregory. "It was just like ..."

"Wait a minute," I interrupt, "you don’t mean ..."

"Yes indeed," says Greg, with a twinkle. "She handed me an apple." Kate laughs in agreement.

There you have it – life imitating Scripture. Although there’s nothing in the Good Book about Adam and Eve hiding under the Tree of Knowledge to keep from getting wet.

Here’s to happy endings, however they start out.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected]. 

"How have you been treating this?" I asked Ivan. He had a rash on his shin.

"Plantain leaves," he explained.

Plantains, of course. Fry ’em or apply ’em.

Home remedies have always intrigued me. Take Preparation H ointment. Good for bags under the eyes, they say. Also good for hemorrhoids. Really good for people who have trouble telling the difference.

Or tea tree oil. I’ve heard about that for years, but never took the time to find out what a tea tree is. A tree shaped like a "T"? A tree that grows tea? A tree made out of tea?

Turns out it is Melaleuca alternifolia, a source of traditional remedies among the indigenous Bundjalung people of Eastern Australia. (Thank you, Wikipedia.) It may kill viruses, bacteria, and fungi. And it makes a dandy shampoo.

Got poison ivy? Try jewelweed (if you can find it). Or rat vein tea (not sure I want to find that). Or boiled sweet fern. Or (of course) tea tree oil.

Do home remedies work? Truth be told, I don’t claim to know one way or the other. Anyhow, I find a different question more interesting – not whether home remedies work, but why people think they do.

The answer to that seems straightforward. People think home remedies work because other people say so. Vicks VapoRub ointment for toenail fungus? Hank says it cleared him right up! His buddy, Frankie, on the other hand, swears by apple cider vinegar for his own toenails. He’s also sure it got rid of Frankie Jr.’s head lice, although back at school, other kids complained that Frankie Jr. smelled like a salad. And his wife Franchette uses it to help reverse the signs of aging.

Which points to something about the popularity of home remedies: There is a big difference between the way patients think and the way doctors do. Many of these cures – most nowadays are either traditional, natural, or both – are supposed to be good for ... well, just about anything. The list of uses for plantains, for instance, includes rashes, wounds, ulcerations, cuts, swelling, sprains, bruises, burns, eczema, cracked lips, poison ivy, mosquito bites, diaper rash, boils, hemorrhoids, blisters, snake bites, spider bites, splinters, and thorns.

Or take another popular item, jojoba oil (that’s ho-HO-ba to you). Named by the Tohono O’odham people of the Sonoran desert (repositories of ancient wisdom, presumably), jojoba is recommended for the treatment of wrinkles; hair loss; joint pain; hemorrhoids (take note, Preparation H nonresponders!); smoker’s cough; and constipation. It also lubricates locks and engines, and it is good for covering homemade cucumbers. Look it up.

Lists like these might make a physician skeptical, prone to wonder which mechanism of action could possibly explain such disparate effects and what studies could be designed to support or refute them. Considerations like these do not generally trouble patients. If something is good, well, it’s just good, for one thing or for many. Doctors split. Patients lump.

I thought I’d heard every folk remedy there is, earnest or whimsical, until Tibor came by last month. A well-spoken gent with a thick, Hungarian accent, Tibor pulled up his shirt and showed me a lot of eczema.

"Two things make it better," he explained. "The first thing, I swim every day in a chlorinated pool to cool it off."

That was a surprise, considering how many eczema patients are convinced that chlorine makes them worse.

And the second?

"Yogurt," he said. "I put on nonfat yogurt." But not just any nonfat yogurt.

"I tried all different kinds," Tibor went on. "I tried flavored yogurt, I tried Greek yogurt. But the best is plain nonfat yogurt."

A controlled experiment!

I asked Tibor where he got the idea for applying yogurt to his rash.

"My mother suggested some kind of peasant remedy when I was a kid," he said. "It may have been sour cream."

So it was some kind of rash, treated with something dairy. I tried to picture little Tibor covered with sour cream. I couldn’t.

"I put the yogurt on last night," said Tibor, proudly rolling up his sleeve to show me an almost eczema-free arm. "See how well it works!"

Anecdotal, perhaps, but still impressive. It cures eczema! It lowers cholesterol! It’s on sale!

Take that, tea tree oil.

Dr. Rockoff practices dermatology in Brookline, Mass.

"How have you been treating this?" I asked Ivan. He had a rash on his shin.

"Plantain leaves," he explained.

Plantains, of course. Fry ’em or apply ’em.

Home remedies have always intrigued me. Take Preparation H ointment. Good for bags under the eyes, they say. Also good for hemorrhoids. Really good for people who have trouble telling the difference.

Or tea tree oil. I’ve heard about that for years, but never took the time to find out what a tea tree is. A tree shaped like a "T"? A tree that grows tea? A tree made out of tea?

Turns out it is Melaleuca alternifolia, a source of traditional remedies among the indigenous Bundjalung people of Eastern Australia. (Thank you, Wikipedia.) It may kill viruses, bacteria, and fungi. And it makes a dandy shampoo.

Got poison ivy? Try jewelweed (if you can find it). Or rat vein tea (not sure I want to find that). Or boiled sweet fern. Or (of course) tea tree oil.

Do home remedies work? Truth be told, I don’t claim to know one way or the other. Anyhow, I find a different question more interesting – not whether home remedies work, but why people think they do.

The answer to that seems straightforward. People think home remedies work because other people say so. Vicks VapoRub ointment for toenail fungus? Hank says it cleared him right up! His buddy, Frankie, on the other hand, swears by apple cider vinegar for his own toenails. He’s also sure it got rid of Frankie Jr.’s head lice, although back at school, other kids complained that Frankie Jr. smelled like a salad. And his wife Franchette uses it to help reverse the signs of aging.

Which points to something about the popularity of home remedies: There is a big difference between the way patients think and the way doctors do. Many of these cures – most nowadays are either traditional, natural, or both – are supposed to be good for ... well, just about anything. The list of uses for plantains, for instance, includes rashes, wounds, ulcerations, cuts, swelling, sprains, bruises, burns, eczema, cracked lips, poison ivy, mosquito bites, diaper rash, boils, hemorrhoids, blisters, snake bites, spider bites, splinters, and thorns.

Or take another popular item, jojoba oil (that’s ho-HO-ba to you). Named by the Tohono O’odham people of the Sonoran desert (repositories of ancient wisdom, presumably), jojoba is recommended for the treatment of wrinkles; hair loss; joint pain; hemorrhoids (take note, Preparation H nonresponders!); smoker’s cough; and constipation. It also lubricates locks and engines, and it is good for covering homemade cucumbers. Look it up.

Lists like these might make a physician skeptical, prone to wonder which mechanism of action could possibly explain such disparate effects and what studies could be designed to support or refute them. Considerations like these do not generally trouble patients. If something is good, well, it’s just good, for one thing or for many. Doctors split. Patients lump.

I thought I’d heard every folk remedy there is, earnest or whimsical, until Tibor came by last month. A well-spoken gent with a thick, Hungarian accent, Tibor pulled up his shirt and showed me a lot of eczema.

"Two things make it better," he explained. "The first thing, I swim every day in a chlorinated pool to cool it off."

That was a surprise, considering how many eczema patients are convinced that chlorine makes them worse.

And the second?

"Yogurt," he said. "I put on nonfat yogurt." But not just any nonfat yogurt.

"I tried all different kinds," Tibor went on. "I tried flavored yogurt, I tried Greek yogurt. But the best is plain nonfat yogurt."

A controlled experiment!

I asked Tibor where he got the idea for applying yogurt to his rash.

"My mother suggested some kind of peasant remedy when I was a kid," he said. "It may have been sour cream."

So it was some kind of rash, treated with something dairy. I tried to picture little Tibor covered with sour cream. I couldn’t.

"I put the yogurt on last night," said Tibor, proudly rolling up his sleeve to show me an almost eczema-free arm. "See how well it works!"

Anecdotal, perhaps, but still impressive. It cures eczema! It lowers cholesterol! It’s on sale!

Take that, tea tree oil.

Dr. Rockoff practices dermatology in Brookline, Mass.

"How have you been treating this?" I asked Ivan. He had a rash on his shin.

"Plantain leaves," he explained.

Plantains, of course. Fry ’em or apply ’em.

Home remedies have always intrigued me. Take Preparation H ointment. Good for bags under the eyes, they say. Also good for hemorrhoids. Really good for people who have trouble telling the difference.

Or tea tree oil. I’ve heard about that for years, but never took the time to find out what a tea tree is. A tree shaped like a "T"? A tree that grows tea? A tree made out of tea?

Turns out it is Melaleuca alternifolia, a source of traditional remedies among the indigenous Bundjalung people of Eastern Australia. (Thank you, Wikipedia.) It may kill viruses, bacteria, and fungi. And it makes a dandy shampoo.

Got poison ivy? Try jewelweed (if you can find it). Or rat vein tea (not sure I want to find that). Or boiled sweet fern. Or (of course) tea tree oil.

Do home remedies work? Truth be told, I don’t claim to know one way or the other. Anyhow, I find a different question more interesting – not whether home remedies work, but why people think they do.

The answer to that seems straightforward. People think home remedies work because other people say so. Vicks VapoRub ointment for toenail fungus? Hank says it cleared him right up! His buddy, Frankie, on the other hand, swears by apple cider vinegar for his own toenails. He’s also sure it got rid of Frankie Jr.’s head lice, although back at school, other kids complained that Frankie Jr. smelled like a salad. And his wife Franchette uses it to help reverse the signs of aging.

Which points to something about the popularity of home remedies: There is a big difference between the way patients think and the way doctors do. Many of these cures – most nowadays are either traditional, natural, or both – are supposed to be good for ... well, just about anything. The list of uses for plantains, for instance, includes rashes, wounds, ulcerations, cuts, swelling, sprains, bruises, burns, eczema, cracked lips, poison ivy, mosquito bites, diaper rash, boils, hemorrhoids, blisters, snake bites, spider bites, splinters, and thorns.

Or take another popular item, jojoba oil (that’s ho-HO-ba to you). Named by the Tohono O’odham people of the Sonoran desert (repositories of ancient wisdom, presumably), jojoba is recommended for the treatment of wrinkles; hair loss; joint pain; hemorrhoids (take note, Preparation H nonresponders!); smoker’s cough; and constipation. It also lubricates locks and engines, and it is good for covering homemade cucumbers. Look it up.

Lists like these might make a physician skeptical, prone to wonder which mechanism of action could possibly explain such disparate effects and what studies could be designed to support or refute them. Considerations like these do not generally trouble patients. If something is good, well, it’s just good, for one thing or for many. Doctors split. Patients lump.

I thought I’d heard every folk remedy there is, earnest or whimsical, until Tibor came by last month. A well-spoken gent with a thick, Hungarian accent, Tibor pulled up his shirt and showed me a lot of eczema.

"Two things make it better," he explained. "The first thing, I swim every day in a chlorinated pool to cool it off."

That was a surprise, considering how many eczema patients are convinced that chlorine makes them worse.

And the second?

"Yogurt," he said. "I put on nonfat yogurt." But not just any nonfat yogurt.

"I tried all different kinds," Tibor went on. "I tried flavored yogurt, I tried Greek yogurt. But the best is plain nonfat yogurt."

A controlled experiment!

I asked Tibor where he got the idea for applying yogurt to his rash.

"My mother suggested some kind of peasant remedy when I was a kid," he said. "It may have been sour cream."

So it was some kind of rash, treated with something dairy. I tried to picture little Tibor covered with sour cream. I couldn’t.

"I put the yogurt on last night," said Tibor, proudly rolling up his sleeve to show me an almost eczema-free arm. "See how well it works!"

Anecdotal, perhaps, but still impressive. It cures eczema! It lowers cholesterol! It’s on sale!

Take that, tea tree oil.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

Thirty years ago, many college patients I saw were covered by a school health policy written by a company I will call James S. Fred Insurance. Because this happened long before electronic claims submissions, we knew that ours were handled by someone named Lucille.

For reasons I no longer recall, I found myself strolling in downtown Boston one afternoon, when I saw a large office building that listed none other than James S. Fred Insurance as a major tenant. I took the elevator to the 17th floor, went in, and asked for Lucille.

Sure enough, sitting in a quiet cubicle, there she was: a pleasant older woman who did the college accounts, a small cog in a massive wheel. When I introduced myself, Lucille recognized my name and greeted me warmly.

"I never expected to meet you in person," I said, "But since I have, perhaps I can tell you about a problem we’re having with reimbursement. I described the issue. Lucille took out a large manual, listing the terms of the company’s college coverage. "Here it is," she said, showing me the relevant paragraph.

I thanked her and took the book. But when I read the paragraph, I saw that it didn’t say what she said it said. I pointed this out.

"My goodness," said Lucille. "You’re right. We should be reimbursing you for that, shouldn’t we?"

So that was it. The massive insurance giant in the glass-and-steel skyscraper turned out to be a little old lady in a cubicle who couldn’t read the manual. It was like pulling back the curtain and finding out that the Wizard of Oz was a geezer with a wind machine.

I thought of this last week when I had a talk about my own personal coverage with a Midwest insurer. The issue turned on their responsibility for covering a service provided by a physician who does not participate in Medicare at all. (Yes, I am on Medicare now.)

Last year, I spoke with a human at the company who explained that all I needed to do was confirm that the provider was not Medicare affiliated. This year, after paying a few claims, they apparently changed their mind and sent letters demanding payback and saying they would only pay what Medicare would have, even if Medicare actually didn’t.

I appealed. The appeal was denied. I could not reach a human. I gave up.

Then last week, Jeanette called from Chicago. She described herself as Head of the Appeals Division, in a voice that sounded like Marian, the no-nonsense librarian from "The Music Man."

"Our policy is based on what’s in the manual," she said. "Let me see if I can find it. Oh, here it is." Then she read a passage about doctors who don’t accept Medicare assignments. "We ask them to submit claims anyway," she explained.

"Forgive me," I said, "but a doctor who doesn’t accept assignment is a Medicare provider, just one who won’t accept as full payment what Medicare allows. My doctor is not a Medicare provider at all. He can’t submit a claim, because he doesn’t have a Medicare provider number."

"My goodness," said Jeanette. "I think you may be right. Have you documented this for us?"

"With every claim," I said. "I followed your company’s instructions, and attached to every claim my doctor’s letter saying he doesn’t participate in Medicare. You should have a dozen or so copies of this letter. If you can’t find any, I’ll be happy to send another."

"Oh, here it is!" said Jeanette. "Yes, I see. We need to rectify this."

I danced a mental jig around the room. Lucille must be long retired, but I’d love to invite her and Jeanette for tea.

"I’m really grateful to have the chance to speak to person," I told Jeanette. "Thanks so much for listening."

You could hear Jeanette glow right through the phone. "Why, you’re welcome," she said. "You’ve made my whole day!"

Faceless bureaucracies can seem intimidating, impersonal, malevolent, diabolical, Kafkaesque.

But sometimes, they’re just little old ladies who have trouble reading manuals. To find out, just follow the yellow brick road.

Dr. Rockoff practices dermatology in Brookline, Mass.

People hate bumps.

Bumps are ugly. Bumps are nasty. Bumps bother.

Seeing bumps makes people frown. Touching bumps makes them shudder.

Bumps on toads. Bumps on potatoes. Bumps on trees.

But especially bumps on skin – on faces, on lips, on tongues, on genitals. Bumps almost anywhere.

Bumps bother the people who have them. They especially agitate other people who have to look at them, so they point out the bumps and make it perfectly plain how bumps make them feel:

• "My wife says, ‘When are you going to get that disgusting red spot off your neck?’" (About a hemangioma.)

• "My kids say, ‘Dad, when are you getting that gross thing off your back?’" (About an epidermoid cyst.)

• "That black spot on your back – have you had that looked at?" (A doctor – not a dermatologist, of course – asks a patient about a dermal nevus you’ve been reassuring that patient about for years.)

"Just leave those skin tags on your neck alone," you say.

"But they’re nasty! Can’t you take them off?"

"I suggest you leave the cyst alone. Removing it would require surgery."

"But I hate it!"

Even nonverbal observers can call attention to bumps. More than one nursing mother has had me remove a mole from her breast, even though it’s been there without changing for a long time, because "the baby keeps grabbing at it."

But once the people who see bumps can talk, it’s open bump season. My wife had a blue nevus removed from her cheek many years ago. She recalls that she did it because our youngest son, about 8 years old at the time, kept pointing to her cheek and saying, "Blue nevus! Blue nevus!" (Yes, he could be irritating then, but no, he wasn’t diagnostically precocious – I’d told him what it was.)

That son now has three children of his own, so he can look to his own parenting challenges, not to mention his own blemishes.

The loaded words people apply to their bumps – ugly, disgusting, gross, nasty – are not the ones you’d expect, and they have nothing to do with histology or malignant potential. But if you listen for these words, you’ll hear them as often as I do.

Some of my bumpy conversations are droll in unexpected ways. Last week, for instance, Seth came in for his annual physical.

"I have these two things under my left arm," he said, pointing to a pair of skin tags.

"Do they bother you?" I asked.

"They bother my kids," he said. "Adam and Melissa keep pointing at them. They call them Fred."

"Fred? What do they call the other one?"

"Also Fred."

"Did you know," I asked him, "that all little thingies hanging off the body are male? People always say, ‘Can’t you get rid of those little guys?’ "

"I didn’t know that," said Seth.

"You see what you can learn at the dermatologist’s office?" I said. "If you want, I can make your kids happy and get rid of Fred. Both of him."

"Sure," said Seth. I loaded up my electric needle. I don’t play video games. Who needs when you have a Hyfrecator? Soon Fred was vaporized. BLAMMM! So was Fred. KAPOWW!

"Seth," I said, "if Dr. Seuss had written a book about dermatology, he might have called it ‘Bye, Bye, Fred’ and it may have gone like this":

See Fred.

Fred bled.

Fred bled red.

Fred bled red in bed.

Zap, Fred! Pow, Fred!

Now Fred is dead.

Sayonara, Fred.

Go ahead, moles, warts, skin tags, bumps of all kinds. Make my day.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

People hate bumps.

Bumps are ugly. Bumps are nasty. Bumps bother.

Seeing bumps makes people frown. Touching bumps makes them shudder.

Bumps on toads. Bumps on potatoes. Bumps on trees.

But especially bumps on skin – on faces, on lips, on tongues, on genitals. Bumps almost anywhere.

Bumps bother the people who have them. They especially agitate other people who have to look at them, so they point out the bumps and make it perfectly plain how bumps make them feel:

• "My wife says, ‘When are you going to get that disgusting red spot off your neck?’" (About a hemangioma.)

• "My kids say, ‘Dad, when are you getting that gross thing off your back?’" (About an epidermoid cyst.)

• "That black spot on your back – have you had that looked at?" (A doctor – not a dermatologist, of course – asks a patient about a dermal nevus you’ve been reassuring that patient about for years.)

"Just leave those skin tags on your neck alone," you say.

"But they’re nasty! Can’t you take them off?"

"I suggest you leave the cyst alone. Removing it would require surgery."

"But I hate it!"

Even nonverbal observers can call attention to bumps. More than one nursing mother has had me remove a mole from her breast, even though it’s been there without changing for a long time, because "the baby keeps grabbing at it."

But once the people who see bumps can talk, it’s open bump season. My wife had a blue nevus removed from her cheek many years ago. She recalls that she did it because our youngest son, about 8 years old at the time, kept pointing to her cheek and saying, "Blue nevus! Blue nevus!" (Yes, he could be irritating then, but no, he wasn’t diagnostically precocious – I’d told him what it was.)

That son now has three children of his own, so he can look to his own parenting challenges, not to mention his own blemishes.

The loaded words people apply to their bumps – ugly, disgusting, gross, nasty – are not the ones you’d expect, and they have nothing to do with histology or malignant potential. But if you listen for these words, you’ll hear them as often as I do.

Some of my bumpy conversations are droll in unexpected ways. Last week, for instance, Seth came in for his annual physical.

"I have these two things under my left arm," he said, pointing to a pair of skin tags.

"Do they bother you?" I asked.

"They bother my kids," he said. "Adam and Melissa keep pointing at them. They call them Fred."

"Fred? What do they call the other one?"

"Also Fred."

"Did you know," I asked him, "that all little thingies hanging off the body are male? People always say, ‘Can’t you get rid of those little guys?’ "

"I didn’t know that," said Seth.

"You see what you can learn at the dermatologist’s office?" I said. "If you want, I can make your kids happy and get rid of Fred. Both of him."

"Sure," said Seth. I loaded up my electric needle. I don’t play video games. Who needs when you have a Hyfrecator? Soon Fred was vaporized. BLAMMM! So was Fred. KAPOWW!

"Seth," I said, "if Dr. Seuss had written a book about dermatology, he might have called it ‘Bye, Bye, Fred’ and it may have gone like this":

See Fred.

Fred bled.

Fred bled red.

Fred bled red in bed.

Zap, Fred! Pow, Fred!

Now Fred is dead.

Sayonara, Fred.

Go ahead, moles, warts, skin tags, bumps of all kinds. Make my day.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

People hate bumps.

Bumps are ugly. Bumps are nasty. Bumps bother.

Seeing bumps makes people frown. Touching bumps makes them shudder.

Bumps on toads. Bumps on potatoes. Bumps on trees.

But especially bumps on skin – on faces, on lips, on tongues, on genitals. Bumps almost anywhere.

Bumps bother the people who have them. They especially agitate other people who have to look at them, so they point out the bumps and make it perfectly plain how bumps make them feel:

• "My wife says, ‘When are you going to get that disgusting red spot off your neck?’" (About a hemangioma.)

• "My kids say, ‘Dad, when are you getting that gross thing off your back?’" (About an epidermoid cyst.)

• "That black spot on your back – have you had that looked at?" (A doctor – not a dermatologist, of course – asks a patient about a dermal nevus you’ve been reassuring that patient about for years.)

"Just leave those skin tags on your neck alone," you say.

"But they’re nasty! Can’t you take them off?"

"I suggest you leave the cyst alone. Removing it would require surgery."

"But I hate it!"

Even nonverbal observers can call attention to bumps. More than one nursing mother has had me remove a mole from her breast, even though it’s been there without changing for a long time, because "the baby keeps grabbing at it."

But once the people who see bumps can talk, it’s open bump season. My wife had a blue nevus removed from her cheek many years ago. She recalls that she did it because our youngest son, about 8 years old at the time, kept pointing to her cheek and saying, "Blue nevus! Blue nevus!" (Yes, he could be irritating then, but no, he wasn’t diagnostically precocious – I’d told him what it was.)

That son now has three children of his own, so he can look to his own parenting challenges, not to mention his own blemishes.

The loaded words people apply to their bumps – ugly, disgusting, gross, nasty – are not the ones you’d expect, and they have nothing to do with histology or malignant potential. But if you listen for these words, you’ll hear them as often as I do.

Some of my bumpy conversations are droll in unexpected ways. Last week, for instance, Seth came in for his annual physical.

"I have these two things under my left arm," he said, pointing to a pair of skin tags.

"Do they bother you?" I asked.

"They bother my kids," he said. "Adam and Melissa keep pointing at them. They call them Fred."

"Fred? What do they call the other one?"

"Also Fred."

"Did you know," I asked him, "that all little thingies hanging off the body are male? People always say, ‘Can’t you get rid of those little guys?’ "

"I didn’t know that," said Seth.

"You see what you can learn at the dermatologist’s office?" I said. "If you want, I can make your kids happy and get rid of Fred. Both of him."

"Sure," said Seth. I loaded up my electric needle. I don’t play video games. Who needs when you have a Hyfrecator? Soon Fred was vaporized. BLAMMM! So was Fred. KAPOWW!

"Seth," I said, "if Dr. Seuss had written a book about dermatology, he might have called it ‘Bye, Bye, Fred’ and it may have gone like this":

See Fred.

Fred bled.

Fred bled red.

Fred bled red in bed.

Zap, Fred! Pow, Fred!

Now Fred is dead.

Sayonara, Fred.

Go ahead, moles, warts, skin tags, bumps of all kinds. Make my day.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My patients itch. Do yours?

This time of year, many of them say their backs itch, but the itch is not really their main concern. What worries them more is what the itch means. They know there are spots back there. They can feel them even if they can’t see them very well. Does the itch mean those spots are turning into something?

Sometimes those spots on their backs are moles. Sometimes they are seborrheic keratoses. But basically they’re all just innocent bystanders. Even if there does happen to be a superficial basal cell back there, any itch in the vicinity has nothing to do with any of the spots.

"Itching," I tell my patients, "is a sign that you are alive." After a short pause for mental processing, most of them smile. Being alive is good. Itch is your friend.

If they don’t smile and instead continue to look anguished, I sometimes freeze off some of their keratoses, just so they can feel reassured. You never know about those pesky growths. They’re benign today, but who knows about tomorrow? And they’re itchy, aren’t they? Doesn’t an itch mean something?

As far as I’m concerned, it doesn’t mean much, or at least not much about malignant transformation. Sometimes a cigar is just a cigar, and mostly an itch is just an itch. But to many of my patients, an itch is much more: Itch is change, itch is instability. Something is happening, something is changing, something is going on. Maybe one thing is turning into something else. Maybe it will.

Last week, I saw a thirtyish woman who wanted a skin check. One of her concerns was an itchy spot on her left shoulder. Lately, it had started to "move down" to her upper arm. As she admitted herself, there was absolutely nothing to be seen on the skin. She couldn’t possibly be worried about ...

Yes, she could. "This isn’t skin cancer, is it?" she asked. I assured her it was not. She seemed to believe me. I couldn’t remove anything anyway, because there was nothing to remove.

I don’t know where people get the idea that itch, especially when it applies to a mole or growth, means possible cancer. But wherever they get the idea, many of them certainly have it. They ask about it all the time. "I’m worried about that mole," they say.

"Do you think it’s changed, gotten larger or darker?"

"No, it looks the same. But now it itches."

People worry, not just about the itch, but about what happens when they scratch it. They’ve been warned since childhood not to scratch. Scratching can cause damage or infection. If what they’re scratching is a spot, then scratching can possibly turn the spot into ... don’t say it!

Of course, people complain about itching for a lot of reasons: They have eczema, or dry skin, or winter itch. Older folks have trouble sleeping because of itch. Office workers are embarrassed by itch – they have to leave meetings to keep their colleagues from twitching uncomfortably when they see them scratch. ("Like a monkey," is usually how they put it.) People who work in nursing homes or homeless shelters worry that they picked up a creepy-crawly from one of their clients. I once read that a king of England forbade commoners from scratching their itches, because scratching was so much fun that he wanted to reserve it for royalty. Couples married 7 years may get the itch. Treatises have been written about itching and scratching. I have not read them. Some things are better enjoyed than read about.

When the itch is accompanied by a visible rash – atopic eczema is the parade example – you treat the itch by treating the rash. When the patient has an itch but no rash other than scratch marks, it’s often best not just to treat the symptom, but to eliminate the worry that accompanies and exaggerates the symptom. No, the itch is not bugs. No, the itch is not liver disease. No, scratching will not cause damage, or you-know-what.

No, the itch is not cancer. There, I said it.

You itch. Itch is life. Celebrate!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My patients itch. Do yours?

This time of year, many of them say their backs itch, but the itch is not really their main concern. What worries them more is what the itch means. They know there are spots back there. They can feel them even if they can’t see them very well. Does the itch mean those spots are turning into something?

Sometimes those spots on their backs are moles. Sometimes they are seborrheic keratoses. But basically they’re all just innocent bystanders. Even if there does happen to be a superficial basal cell back there, any itch in the vicinity has nothing to do with any of the spots.

"Itching," I tell my patients, "is a sign that you are alive." After a short pause for mental processing, most of them smile. Being alive is good. Itch is your friend.

If they don’t smile and instead continue to look anguished, I sometimes freeze off some of their keratoses, just so they can feel reassured. You never know about those pesky growths. They’re benign today, but who knows about tomorrow? And they’re itchy, aren’t they? Doesn’t an itch mean something?

As far as I’m concerned, it doesn’t mean much, or at least not much about malignant transformation. Sometimes a cigar is just a cigar, and mostly an itch is just an itch. But to many of my patients, an itch is much more: Itch is change, itch is instability. Something is happening, something is changing, something is going on. Maybe one thing is turning into something else. Maybe it will.

Last week, I saw a thirtyish woman who wanted a skin check. One of her concerns was an itchy spot on her left shoulder. Lately, it had started to "move down" to her upper arm. As she admitted herself, there was absolutely nothing to be seen on the skin. She couldn’t possibly be worried about ...

Yes, she could. "This isn’t skin cancer, is it?" she asked. I assured her it was not. She seemed to believe me. I couldn’t remove anything anyway, because there was nothing to remove.

I don’t know where people get the idea that itch, especially when it applies to a mole or growth, means possible cancer. But wherever they get the idea, many of them certainly have it. They ask about it all the time. "I’m worried about that mole," they say.

"Do you think it’s changed, gotten larger or darker?"

"No, it looks the same. But now it itches."

People worry, not just about the itch, but about what happens when they scratch it. They’ve been warned since childhood not to scratch. Scratching can cause damage or infection. If what they’re scratching is a spot, then scratching can possibly turn the spot into ... don’t say it!

Of course, people complain about itching for a lot of reasons: They have eczema, or dry skin, or winter itch. Older folks have trouble sleeping because of itch. Office workers are embarrassed by itch – they have to leave meetings to keep their colleagues from twitching uncomfortably when they see them scratch. ("Like a monkey," is usually how they put it.) People who work in nursing homes or homeless shelters worry that they picked up a creepy-crawly from one of their clients. I once read that a king of England forbade commoners from scratching their itches, because scratching was so much fun that he wanted to reserve it for royalty. Couples married 7 years may get the itch. Treatises have been written about itching and scratching. I have not read them. Some things are better enjoyed than read about.

When the itch is accompanied by a visible rash – atopic eczema is the parade example – you treat the itch by treating the rash. When the patient has an itch but no rash other than scratch marks, it’s often best not just to treat the symptom, but to eliminate the worry that accompanies and exaggerates the symptom. No, the itch is not bugs. No, the itch is not liver disease. No, scratching will not cause damage, or you-know-what.

No, the itch is not cancer. There, I said it.

You itch. Itch is life. Celebrate!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My patients itch. Do yours?

This time of year, many of them say their backs itch, but the itch is not really their main concern. What worries them more is what the itch means. They know there are spots back there. They can feel them even if they can’t see them very well. Does the itch mean those spots are turning into something?

Sometimes those spots on their backs are moles. Sometimes they are seborrheic keratoses. But basically they’re all just innocent bystanders. Even if there does happen to be a superficial basal cell back there, any itch in the vicinity has nothing to do with any of the spots.

"Itching," I tell my patients, "is a sign that you are alive." After a short pause for mental processing, most of them smile. Being alive is good. Itch is your friend.

If they don’t smile and instead continue to look anguished, I sometimes freeze off some of their keratoses, just so they can feel reassured. You never know about those pesky growths. They’re benign today, but who knows about tomorrow? And they’re itchy, aren’t they? Doesn’t an itch mean something?

As far as I’m concerned, it doesn’t mean much, or at least not much about malignant transformation. Sometimes a cigar is just a cigar, and mostly an itch is just an itch. But to many of my patients, an itch is much more: Itch is change, itch is instability. Something is happening, something is changing, something is going on. Maybe one thing is turning into something else. Maybe it will.

Last week, I saw a thirtyish woman who wanted a skin check. One of her concerns was an itchy spot on her left shoulder. Lately, it had started to "move down" to her upper arm. As she admitted herself, there was absolutely nothing to be seen on the skin. She couldn’t possibly be worried about ...

Yes, she could. "This isn’t skin cancer, is it?" she asked. I assured her it was not. She seemed to believe me. I couldn’t remove anything anyway, because there was nothing to remove.

I don’t know where people get the idea that itch, especially when it applies to a mole or growth, means possible cancer. But wherever they get the idea, many of them certainly have it. They ask about it all the time. "I’m worried about that mole," they say.

"Do you think it’s changed, gotten larger or darker?"

"No, it looks the same. But now it itches."

People worry, not just about the itch, but about what happens when they scratch it. They’ve been warned since childhood not to scratch. Scratching can cause damage or infection. If what they’re scratching is a spot, then scratching can possibly turn the spot into ... don’t say it!

Of course, people complain about itching for a lot of reasons: They have eczema, or dry skin, or winter itch. Older folks have trouble sleeping because of itch. Office workers are embarrassed by itch – they have to leave meetings to keep their colleagues from twitching uncomfortably when they see them scratch. ("Like a monkey," is usually how they put it.) People who work in nursing homes or homeless shelters worry that they picked up a creepy-crawly from one of their clients. I once read that a king of England forbade commoners from scratching their itches, because scratching was so much fun that he wanted to reserve it for royalty. Couples married 7 years may get the itch. Treatises have been written about itching and scratching. I have not read them. Some things are better enjoyed than read about.

When the itch is accompanied by a visible rash – atopic eczema is the parade example – you treat the itch by treating the rash. When the patient has an itch but no rash other than scratch marks, it’s often best not just to treat the symptom, but to eliminate the worry that accompanies and exaggerates the symptom. No, the itch is not bugs. No, the itch is not liver disease. No, scratching will not cause damage, or you-know-what.

No, the itch is not cancer. There, I said it.

You itch. Itch is life. Celebrate!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

"Do you think I need Botox?" Nora asks.

This is her first visit. On the sign-in sheet, next to "Reason for today’s visit," she’s written, "Mole check. Questions about Botox and fillers. Skin care advice." I check the moles on her neck that concern her.

"I just turned 40." she says, "Is Botox is something I ought to do? My wrinkles aren’t so deep" – she furrows her face, "but maybe I should do it before they get deeper.

"I just moved to Boston from Los Angeles," she continues. "I saw an esthetician there, who looked at the hollows under my eyes and said, ‘You definitely need Juvéderm.’ Do you think I need that?"

Nora is obviously a "cosmetic" patient, but the problem with labeling her that way has something in common with labeling any patient, even a "medical" one, as an individual, in isolation. No one lives in isolation. We live with other people, and what we think of our health, or our appearance, has a lot to do with what other people think.

How many patients come in with an itch, a rash, or a lesion, that’s been there a long time? Why come today? Because someone – a relative, friend, grandchild – said, "Get that looked at!" The relevance of this homely observation is that we don’t necessarily have to bother people with treatment for symptoms that don’t trouble them just because they bother other people in their vicinity: A few unobtrusive spots of psoriasis, some pimples on the mid-back, a keratosis. If it isn’t scabies, we can leave the family out of it.

Medical school teaches us to take a social history: Where does the patient live? What’s her occupation? Family background? You can use this as a bullet point for coding purposes. But there is no slot for the social context of the disease. We only look at the individual. If the question is medical, we’re supposed to ask whether the patient has a disease, and if so which one? If it’s cosmetic, is the patient vain, narcissistic, perhaps dysmorphic? Who cares what their neighbors are saying?

Actually, patients do. When my son moved from Manhattan to Beverly Hills, within days several people had taken one look at his beat-up car and announced, "You can’t drive that! It has to be detailed." He didn’t know what that meant (I still don’t), but he detailed it soon enough. A year later he moved back east, where the car quickly undetailed.

Boston is more buttoned down, but here, too, what people say matters. Matrons who pahk their cah near Hahvahd Yahd don’t color their gray hair. One who does would stand out. In the western suburbs ladies of a certain age do their faces. One who doesn’t grows uneasy. "Shouldn’t I be doing something?" she wonders.

Most people don’t like to stand out. Attention makes them uncomfortable. They would rather not have other people take note of any deviance, whether symptoms or wrinkles.

So let’s get back to Nora. Her moles are clearly a pretext for her real concern, which is whether she should be doing something about aging. Was the esthetician in L.A. right?

A rounded summary of Nora’s predicament would sound something like this: The patient is concerned about getting old and deteriorating. In her mind’s eye are images of people she has known who aged well or poorly. In her ears are statements made by people who told her to do something or warned her to stay away from doing anything. In her mirror is a largely unlined face with a few furrows on the forehead. What will people say if she takes action? What will they say if she doesn’t?

Poor Nora. If I’m making her sound like Hamlet, that’s because in this sense she is. But enough philosophy, let’s talk about what’s important: How should we code her visit? We’ll choose the evaluation and management code of appropriate complexity and list the diagnosis as "Nevus, benign." We will feed this into the giant medical data machine in the cloud. This information will capture precisely nothing about what her visit was really about. But what can you do? Even ICD-10, with its 140,000 diagnoses, won’t have one for "Angst promoted by the social milieu."

Maybe ICD-11.

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

My friend had a cyst removed from the end of her right fourth finger. She told me that it’s healing well and she’s happy with the doctor’s work.

"Who removed it?" I asked her.

She gave me the name of a hand surgeon at a local teaching hospital.

"Did you compare alternatives for cost?" I asked her.

She had gotten another surgical opinion, but didn’t really understand my question about cost comparison. My friend is a retired attorney who knows me well enough to realize I’m not always totally serious.

I told her about the current thrust to make consumers (i.e., patients) more cost conscious by giving them "more skin in the game" (making it worth their while to get the best deal they can, as they would when, say, buying a flat-screen TV).

When I explained to my friend what I meant, she told me she wasn’t sure how well that would work. I told her that although I have skin in the skin game, I’m not so sure either.

Changes are in the wind. I got an e-mail the other day from a patient whose leg I had recently biopsied. I had told him that the result showed a fairly large basal cell and recommended excision, suggesting either of two surgeons.

His answer was: "Thanks. I will compare their costs and let you know which one I pick."

I responded that doing that would be fine, but might be complicated by the fact that one of the surgeons does Mohs, so to compare prices he would need to consult that doctor first and find out which technique he would use.

Perhaps I shouldn’t have been put off by his e-mail, but I was. It seemed to imply that a professional recommendation is on the same plane as advice about picking a lawn mower. Is it? I was saying (or thought I was saying): "Here are two doctors whose work I know and trust." Reducing that to dollars and cents makes it something else, something less.

What it actually does is to reduce my professional opinion to shopping advice, which is in fact exactly what market-based incentives are supposed to do.

I thought of this push for cost consciousness a few months ago, when my wife had back surgery. We got several opinions: Laminectomy? Laminectomy with fusion? Even when surgeons at different hospitals recommended the same procedure, we did not ask what reimbursement rate the respective institution had negotiated with our insurer. (There are, of course, big differences, based not on quality – whatever that is – but on each hospital network’s market clout.)

The surgeon we picked arranged for several preoperative visits. At one of them the nurse said my wife would need a CT scan. We went right up one floor, and she had it done.

But should we have? There had already been an MRI. Was a CT scan really needed? And if it was, would we get the best price upstairs, or maybe across town?

Did my wife know? As a dermatologist, did I? Of course not. What would it have meant for us to say, "Hold on now, we’ve got skin in this game. We’d like to know why you need a CT scan. Is it really necessary? Is this the most cost-effective place to do it?"

Would that have been a shopping question, or a professional challenge? What would my friend’s hand surgeon have said if she asked him for a quote, or brought in one from another surgeon? Is buying surgery similar to bringing in a competitor’s coupon to Wal-Mart, or scanning a bookstore’s barcode on the Amazon app to see if they can match or beat it?

The powers shaping health care are not likely to be moved by such questions. They will point out – correctly – that medical costs are out of control, and therefore something must be done. They will therefore do something, as they are doing with electronic health records and will shortly do with ICD-10. The consequences of all these actions, intended and otherwise, remain to be seen both to doctors as providers and to all of us as consumers.

In the meantime, I have downloaded a discount coupon from the web: 10% off on any cystoscopy, but only if I act now and bring along 10 friends.

Let’s go, guys!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at at [email protected].

My friend had a cyst removed from the end of her right fourth finger. She told me that it’s healing well and she’s happy with the doctor’s work.

"Who removed it?" I asked her.

She gave me the name of a hand surgeon at a local teaching hospital.

"Did you compare alternatives for cost?" I asked her.

She had gotten another surgical opinion, but didn’t really understand my question about cost comparison. My friend is a retired attorney who knows me well enough to realize I’m not always totally serious.

I told her about the current thrust to make consumers (i.e., patients) more cost conscious by giving them "more skin in the game" (making it worth their while to get the best deal they can, as they would when, say, buying a flat-screen TV).

When I explained to my friend what I meant, she told me she wasn’t sure how well that would work. I told her that although I have skin in the skin game, I’m not so sure either.

Changes are in the wind. I got an e-mail the other day from a patient whose leg I had recently biopsied. I had told him that the result showed a fairly large basal cell and recommended excision, suggesting either of two surgeons.

His answer was: "Thanks. I will compare their costs and let you know which one I pick."

I responded that doing that would be fine, but might be complicated by the fact that one of the surgeons does Mohs, so to compare prices he would need to consult that doctor first and find out which technique he would use.

Perhaps I shouldn’t have been put off by his e-mail, but I was. It seemed to imply that a professional recommendation is on the same plane as advice about picking a lawn mower. Is it? I was saying (or thought I was saying): "Here are two doctors whose work I know and trust." Reducing that to dollars and cents makes it something else, something less.

What it actually does is to reduce my professional opinion to shopping advice, which is in fact exactly what market-based incentives are supposed to do.

I thought of this push for cost consciousness a few months ago, when my wife had back surgery. We got several opinions: Laminectomy? Laminectomy with fusion? Even when surgeons at different hospitals recommended the same procedure, we did not ask what reimbursement rate the respective institution had negotiated with our insurer. (There are, of course, big differences, based not on quality – whatever that is – but on each hospital network’s market clout.)

The surgeon we picked arranged for several preoperative visits. At one of them the nurse said my wife would need a CT scan. We went right up one floor, and she had it done.

But should we have? There had already been an MRI. Was a CT scan really needed? And if it was, would we get the best price upstairs, or maybe across town?

Did my wife know? As a dermatologist, did I? Of course not. What would it have meant for us to say, "Hold on now, we’ve got skin in this game. We’d like to know why you need a CT scan. Is it really necessary? Is this the most cost-effective place to do it?"

Would that have been a shopping question, or a professional challenge? What would my friend’s hand surgeon have said if she asked him for a quote, or brought in one from another surgeon? Is buying surgery similar to bringing in a competitor’s coupon to Wal-Mart, or scanning a bookstore’s barcode on the Amazon app to see if they can match or beat it?

The powers shaping health care are not likely to be moved by such questions. They will point out – correctly – that medical costs are out of control, and therefore something must be done. They will therefore do something, as they are doing with electronic health records and will shortly do with ICD-10. The consequences of all these actions, intended and otherwise, remain to be seen both to doctors as providers and to all of us as consumers.

In the meantime, I have downloaded a discount coupon from the web: 10% off on any cystoscopy, but only if I act now and bring along 10 friends.

Let’s go, guys!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at at [email protected].

My friend had a cyst removed from the end of her right fourth finger. She told me that it’s healing well and she’s happy with the doctor’s work.

"Who removed it?" I asked her.

She gave me the name of a hand surgeon at a local teaching hospital.

"Did you compare alternatives for cost?" I asked her.

She had gotten another surgical opinion, but didn’t really understand my question about cost comparison. My friend is a retired attorney who knows me well enough to realize I’m not always totally serious.

I told her about the current thrust to make consumers (i.e., patients) more cost conscious by giving them "more skin in the game" (making it worth their while to get the best deal they can, as they would when, say, buying a flat-screen TV).

When I explained to my friend what I meant, she told me she wasn’t sure how well that would work. I told her that although I have skin in the skin game, I’m not so sure either.

Changes are in the wind. I got an e-mail the other day from a patient whose leg I had recently biopsied. I had told him that the result showed a fairly large basal cell and recommended excision, suggesting either of two surgeons.

His answer was: "Thanks. I will compare their costs and let you know which one I pick."

I responded that doing that would be fine, but might be complicated by the fact that one of the surgeons does Mohs, so to compare prices he would need to consult that doctor first and find out which technique he would use.

Perhaps I shouldn’t have been put off by his e-mail, but I was. It seemed to imply that a professional recommendation is on the same plane as advice about picking a lawn mower. Is it? I was saying (or thought I was saying): "Here are two doctors whose work I know and trust." Reducing that to dollars and cents makes it something else, something less.

What it actually does is to reduce my professional opinion to shopping advice, which is in fact exactly what market-based incentives are supposed to do.

I thought of this push for cost consciousness a few months ago, when my wife had back surgery. We got several opinions: Laminectomy? Laminectomy with fusion? Even when surgeons at different hospitals recommended the same procedure, we did not ask what reimbursement rate the respective institution had negotiated with our insurer. (There are, of course, big differences, based not on quality – whatever that is – but on each hospital network’s market clout.)

The surgeon we picked arranged for several preoperative visits. At one of them the nurse said my wife would need a CT scan. We went right up one floor, and she had it done.

But should we have? There had already been an MRI. Was a CT scan really needed? And if it was, would we get the best price upstairs, or maybe across town?

Did my wife know? As a dermatologist, did I? Of course not. What would it have meant for us to say, "Hold on now, we’ve got skin in this game. We’d like to know why you need a CT scan. Is it really necessary? Is this the most cost-effective place to do it?"

Would that have been a shopping question, or a professional challenge? What would my friend’s hand surgeon have said if she asked him for a quote, or brought in one from another surgeon? Is buying surgery similar to bringing in a competitor’s coupon to Wal-Mart, or scanning a bookstore’s barcode on the Amazon app to see if they can match or beat it?

The powers shaping health care are not likely to be moved by such questions. They will point out – correctly – that medical costs are out of control, and therefore something must be done. They will therefore do something, as they are doing with electronic health records and will shortly do with ICD-10. The consequences of all these actions, intended and otherwise, remain to be seen both to doctors as providers and to all of us as consumers.

In the meantime, I have downloaded a discount coupon from the web: 10% off on any cystoscopy, but only if I act now and bring along 10 friends.

Let’s go, guys!

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail Dr. Rockoff at at [email protected].

When my wife was hospitalized for back surgery, I learned more about the new information revolution in health care that provides formerly unattainable precision. This investigative report includes suggestions for how we, in the outpatient world, can implement these advances.

At a 3-hour preop marathon, my wife was interviewed by several people, including two nurses. The neurosurgery nurse practitioner asked my wife how much pain she was experiencing.

"It depends on my position," my wife answered. "If I’m sitting, it’s not that painful."

"But when it does hurt?"

"Well, it isn’t that bad."

"On a scale of 1-10?"

"Four."

Later on the anesthesia nurse asked her many questions. One was, "How much pain are you in, on a scale of 1-10?"

"It depends," began my wife, a slow learner.

"On a scale of 1-10?"

"Four."

Things went smoothly after that until the final question, "Do you feel safe at home?"

I had kept my mouth shut until then, but at that point, I got clarification that she was, indeed, asking whether my wife feared being abused after discharge. Not an unfair question, though I did wonder whether someone who really wanted to know would ask the question while a potential abuser looked on.

On the morning of surgery a clerk asked my wife again how much pain she was in, on a scale of one 1-10. In the recovery room they asked her again, several times.

Once my wife reached the ward, each nurse asked, once per shift, how much pain she had, on a scale of 1-10. At first, she tried to explain through her opiate stupor, what she was feeling.

"On a scale of 1-10," came the polite but insistent request. I doubt whether my wife remembered 5 minutes later what number she had given, which had in any case been duly noted and entered into the computer.

Ditto the aides. Ditto the physical therapist. Ditto the occupational therapist. At each visit.

Back home the visiting nurse’s aid called to visit and set up services. Before the nurse came, I said to my wife, "Let’s practice."

"Practice what?"

"Saying ‘four’ "

"Why four?"

"Because she’s going to ask you how much pain you’re having, on a scale of 1-10."

"But it isn’t four."

"Okay, say three."

The nurse came. Her first question was, "How much pain are you having, on a scale of 1-10?"

My wife tried again to give a nuanced answer. But eventually she did say, "Four."

The nurse asked my wife whether she was depressed. "Starting last month, they’re making us ask that."

My wife laughed. "I feel wonderful!" she said. "I don’t look depressed, do I?"

"I need a ‘yes’ or ‘no,’ " said the nurse.

"No," said my wife.

"Thank you," said the nurse, wearily. "I have a 30-page form to fill out for every case."

All of the "yes" and "no" replies, and all the numbers from 1-10, will be recorded and filed in the great information repository in the sky.

We can easily apply this method to our own practices.

Consider:

"Mr. Smith, how is your eczema?"

"Doing better, Doc, thanks."

"Great. How much does it itch, on a scale of 1-10?"

"Well, it’s worse at night."

"On a scale of 1-10, please."

"At night, or when I’m working?"

"On a scale of 1-10."

"Two."

"Excellent. How regular have you been with the application?"

"Pretty regular."

"On a scale of 1-10."

"What?"

"How happy are you with the service you received in this office?"

"Well, pretty happy, I guess."

"On a scale of 1-5, with five being ‘Very happy.’  "

"I suppose three."

"How likely are you to use our services again, or to refer a friend, on a scale of 1-6, with six being, ‘You bet!’ and one being, ‘No way, Jose!’?"

"Look, I think that’s enough."

"Just a few more questions, Mr. Smith. Mr. Smith, why are you staring at me like that? Mr. Smith, please get your hands off my neck. What? How much ... do I want ... you to stop ... throttling me? A lot! What? On a scale of 1-10? 10! 10!"

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my wife was hospitalized for back surgery, I learned more about the new information revolution in health care that provides formerly unattainable precision. This investigative report includes suggestions for how we, in the outpatient world, can implement these advances.

At a 3-hour preop marathon, my wife was interviewed by several people, including two nurses. The neurosurgery nurse practitioner asked my wife how much pain she was experiencing.

"It depends on my position," my wife answered. "If I’m sitting, it’s not that painful."

"But when it does hurt?"

"Well, it isn’t that bad."

"On a scale of 1-10?"

"Four."

Later on the anesthesia nurse asked her many questions. One was, "How much pain are you in, on a scale of 1-10?"

"It depends," began my wife, a slow learner.

"On a scale of 1-10?"

"Four."

Things went smoothly after that until the final question, "Do you feel safe at home?"

I had kept my mouth shut until then, but at that point, I got clarification that she was, indeed, asking whether my wife feared being abused after discharge. Not an unfair question, though I did wonder whether someone who really wanted to know would ask the question while a potential abuser looked on.

On the morning of surgery a clerk asked my wife again how much pain she was in, on a scale of one 1-10. In the recovery room they asked her again, several times.

Once my wife reached the ward, each nurse asked, once per shift, how much pain she had, on a scale of 1-10. At first, she tried to explain through her opiate stupor, what she was feeling.

"On a scale of 1-10," came the polite but insistent request. I doubt whether my wife remembered 5 minutes later what number she had given, which had in any case been duly noted and entered into the computer.

Ditto the aides. Ditto the physical therapist. Ditto the occupational therapist. At each visit.

Back home the visiting nurse’s aid called to visit and set up services. Before the nurse came, I said to my wife, "Let’s practice."

"Practice what?"

"Saying ‘four’ "

"Why four?"

"Because she’s going to ask you how much pain you’re having, on a scale of 1-10."

"But it isn’t four."

"Okay, say three."

The nurse came. Her first question was, "How much pain are you having, on a scale of 1-10?"

My wife tried again to give a nuanced answer. But eventually she did say, "Four."

The nurse asked my wife whether she was depressed. "Starting last month, they’re making us ask that."

My wife laughed. "I feel wonderful!" she said. "I don’t look depressed, do I?"

"I need a ‘yes’ or ‘no,’ " said the nurse.

"No," said my wife.

"Thank you," said the nurse, wearily. "I have a 30-page form to fill out for every case."

All of the "yes" and "no" replies, and all the numbers from 1-10, will be recorded and filed in the great information repository in the sky.

We can easily apply this method to our own practices.

Consider:

"Mr. Smith, how is your eczema?"

"Doing better, Doc, thanks."

"Great. How much does it itch, on a scale of 1-10?"

"Well, it’s worse at night."

"On a scale of 1-10, please."

"At night, or when I’m working?"

"On a scale of 1-10."

"Two."

"Excellent. How regular have you been with the application?"

"Pretty regular."

"On a scale of 1-10."

"What?"

"How happy are you with the service you received in this office?"

"Well, pretty happy, I guess."

"On a scale of 1-5, with five being ‘Very happy.’  "

"I suppose three."

"How likely are you to use our services again, or to refer a friend, on a scale of 1-6, with six being, ‘You bet!’ and one being, ‘No way, Jose!’?"

"Look, I think that’s enough."

"Just a few more questions, Mr. Smith. Mr. Smith, why are you staring at me like that? Mr. Smith, please get your hands off my neck. What? How much ... do I want ... you to stop ... throttling me? A lot! What? On a scale of 1-10? 10! 10!"

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].

When my wife was hospitalized for back surgery, I learned more about the new information revolution in health care that provides formerly unattainable precision. This investigative report includes suggestions for how we, in the outpatient world, can implement these advances.

At a 3-hour preop marathon, my wife was interviewed by several people, including two nurses. The neurosurgery nurse practitioner asked my wife how much pain she was experiencing.

"It depends on my position," my wife answered. "If I’m sitting, it’s not that painful."

"But when it does hurt?"

"Well, it isn’t that bad."

"On a scale of 1-10?"

"Four."

Later on the anesthesia nurse asked her many questions. One was, "How much pain are you in, on a scale of 1-10?"

"It depends," began my wife, a slow learner.

"On a scale of 1-10?"

"Four."

Things went smoothly after that until the final question, "Do you feel safe at home?"

I had kept my mouth shut until then, but at that point, I got clarification that she was, indeed, asking whether my wife feared being abused after discharge. Not an unfair question, though I did wonder whether someone who really wanted to know would ask the question while a potential abuser looked on.

On the morning of surgery a clerk asked my wife again how much pain she was in, on a scale of one 1-10. In the recovery room they asked her again, several times.

Once my wife reached the ward, each nurse asked, once per shift, how much pain she had, on a scale of 1-10. At first, she tried to explain through her opiate stupor, what she was feeling.

"On a scale of 1-10," came the polite but insistent request. I doubt whether my wife remembered 5 minutes later what number she had given, which had in any case been duly noted and entered into the computer.

Ditto the aides. Ditto the physical therapist. Ditto the occupational therapist. At each visit.

Back home the visiting nurse’s aid called to visit and set up services. Before the nurse came, I said to my wife, "Let’s practice."

"Practice what?"

"Saying ‘four’ "

"Why four?"

"Because she’s going to ask you how much pain you’re having, on a scale of 1-10."

"But it isn’t four."

"Okay, say three."

The nurse came. Her first question was, "How much pain are you having, on a scale of 1-10?"

My wife tried again to give a nuanced answer. But eventually she did say, "Four."

The nurse asked my wife whether she was depressed. "Starting last month, they’re making us ask that."

My wife laughed. "I feel wonderful!" she said. "I don’t look depressed, do I?"

"I need a ‘yes’ or ‘no,’ " said the nurse.

"No," said my wife.

"Thank you," said the nurse, wearily. "I have a 30-page form to fill out for every case."

All of the "yes" and "no" replies, and all the numbers from 1-10, will be recorded and filed in the great information repository in the sky.

We can easily apply this method to our own practices.

Consider:

"Mr. Smith, how is your eczema?"

"Doing better, Doc, thanks."

"Great. How much does it itch, on a scale of 1-10?"

"Well, it’s worse at night."

"On a scale of 1-10, please."

"At night, or when I’m working?"

"On a scale of 1-10."

"Two."

"Excellent. How regular have you been with the application?"

"Pretty regular."

"On a scale of 1-10."

"What?"

"How happy are you with the service you received in this office?"

"Well, pretty happy, I guess."

"On a scale of 1-5, with five being ‘Very happy.’  "

"I suppose three."

"How likely are you to use our services again, or to refer a friend, on a scale of 1-6, with six being, ‘You bet!’ and one being, ‘No way, Jose!’?"

"Look, I think that’s enough."

"Just a few more questions, Mr. Smith. Mr. Smith, why are you staring at me like that? Mr. Smith, please get your hands off my neck. What? How much ... do I want ... you to stop ... throttling me? A lot! What? On a scale of 1-10? 10! 10!"

Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].