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Two Forms of Contraception
Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."
Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.
Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.
I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.
"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.
I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."
A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."
I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."
"No," said Victoria, "I wasn’t on the patch anymore."
"What?!" I exclaimed.
"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."
"Wasn’t there anyone else in her office who could refill it for you?" I asked.
"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."
I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.
And when she ran out of contraceptive patches, she didn’t get them refilled.
Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.
Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.
The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.
Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.
After all, we have them ourselves.
Dr. Rockoff practices dermatology in Brookline, Mass.
Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."
Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.
Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.
I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.
"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.
I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."
A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."
I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."
"No," said Victoria, "I wasn’t on the patch anymore."
"What?!" I exclaimed.
"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."
"Wasn’t there anyone else in her office who could refill it for you?" I asked.
"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."
I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.
And when she ran out of contraceptive patches, she didn’t get them refilled.
Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.
Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.
The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.
Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.
After all, we have them ourselves.
Dr. Rockoff practices dermatology in Brookline, Mass.
Until last month, I had only ever had two positive pregnancy test results in women of child-bearing age taking isotretinoin. Both of the previous reports came in on the same day, one after the other. When I called each patient to give her the results, and asked her to repeat the test, neither was at all perturbed. "If I’m pregnant," laughed one, "it would be another Immaculate Conception."
Both results turned out to be laboratory errors committed by a single technician, who was reported and rebuked. Repeat tests were negative.
Then, last month, I got another positive. Victoria had actually completed her treatment course 6 weeks earlier, and had already obtained a 30-day post-treatment test – which was negative. Then, she had another test done a few weeks later, which was positive.
I called and got her mother, who asked, "Is everything all right?" But Victoria is 19, so I just said I needed her daughter’s cell phone number.
"We had a condom accident," Victoria said when I reached her. We reviewed her case, determining the last day she had actually taken the medication. Her sexual activity had clearly taken place more than 30 days later.
I suggested she contact her gynecologist at once, to be evaluated and to have the pregnancy test repeated, and I faxed a note to that physician with the relevant details. "If pregnancy is confirmed," I told her, "I’m sure you’ll consider many things before you decide what to do. But one thing you don’t have to factor in is your isotretinoin treatment, because it was no longer in your blood when you became pregnant."
A few days later, Victoria came to my office. "I’ve decided to end the pregnancy," she said. "This just isn’t the right time."
I told her I understood. "By the way," I said, "you listed your two methods of contraception as the patch and condoms. So even if the condom failed, it looks like the patch did too."
"No," said Victoria, "I wasn’t on the patch anymore."
"What?!" I exclaimed.
"I ran out a month earlier," she said, "and my regular doctor was out on maternity leave."
"Wasn’t there anyone else in her office who could refill it for you?" I asked.
"I guess so," she said, "but I kept calling and pushing the button for ‘prescription refills,’ and no one ever called back."
I tried my best not to shake my head in disbelief. Victoria is an intelligent young woman. There is no language barrier. We had discussed contraception before she started therapy, and she signed all the right forms. Each month she got a pregnancy test. Each month she went online and answered the contraceptive-related questions before she could get more isotretinoin.
And when she ran out of contraceptive patches, she didn’t get them refilled.
Victoria’s story could have been worse. She might have become pregnant while still taking isotretinoin. She might have been forced to make a decision to terminate a pregnancy she otherwise would have wanted to carry to term.
Victoria’s story speaks for itself. Despite our best efforts, persuasive or bureaucratic, people will sometimes act in ways that they themselves know perfectly well are against their own interests.
The newest iPledge program upgrade includes some changes, some of which are helpful. One novelty, however, is that if "Abstinence" is the first form of contraception, "None" automatically becomes the second – there is a new warning that this is "Not recommended." This means we should not rely on a patient’s self-reported abstinence, but are better off relying on her use of artificial contraception. Perhaps. But perhaps not. Contraception only works if you use it.
Humans have what a psychiatrist I know calls "design flaws." If ever called upon to redesign the species, I’m sure many of us would contribute some good ideas. In the meantime, however, all we can do is try to acknowledge these flaws, and do our best to mitigate their impact.
After all, we have them ourselves.
Dr. Rockoff practices dermatology in Brookline, Mass.
Marketing
A couple weeks ago I visited a nondermatologist colleague at a famous academic hospital. (Boston has many.) The floor of each landing in the parking garage was emblazoned with a message: "Highest in Customer Satisfaction!" A huge banner across the hospital’s front entrance read, "Rated #1 by U.S. News & World Report!"
The crowded lobby had a futuristic sculpture, a CVS Pharmacy, an Au Bon Pain cafe, and a franchise gift shop. Alongside a central seating area was a display of medical breakthroughs by the hospital’s staff. The lobby’s ambience felt quite similar to that of the new eastbound rest area near exit 9 on the Massachusetts Turnpike, though the highway facility has more restaurants.
Some of you may despair at hearing this. You may not have a restaurant in your waiting room, or even a Keurig coffee dispenser and flat-screen television flashing promotional announcements, as my ophthalmologist does. But fear not, dear colleagues – this columnist rides to your rescue!
Branding
I admit that I watched too much of "The Roy Rogers Show" as a kid to be able to hear the word branding without thinking cow rumps and red-hot pokers. But today you want to be not just a doctor but a brand, the way tissues are Kleenex and Google is searches. But how?
One technique large companies use is audio branding – associating their name with a short series of tones. Think of the five tinkling notes at the end of every T-Mobil commercial, or the "Ba Da Ba Ba Ba – I’m Lovin’ It!" of McDonald’s.
Because I can’t afford a composer, human or computerized, I needed something in the public domain. I got it, the first four notes of Beethoven’s Fifth Symphony. Here’s what you’ll hear on my new telephone outgoing message (and in the videos on my website): "Welcome to the office of Dr. Alan Rockoff – DA-DA-DA-DUMMMM!" Hey, it’s got pizzazz, even gravitas.
I know you’re jealous that I thought of this, but don’t even think of using it. You can have the Sixth Symphony.
Customer Satisfaction Surveys
After I took my Subaru in for a lube, oil, and filer service, the dealer sent me an e-mail customer satisfaction survey. Two days later I received a phone call reminding me that I hadn’t filled it out yet, so I did. Then I got another phone call. It would be just six questions.
"I filled out the survey already. Honest!" I said.
"On a scale of 1 to 5, with 5 being ‘excellent,’ how would you rate your experience?" asked the voice. "5!" I replied, to each of the questions. "On the survey," she continued, "you understand that for any rating less than ‘excellent,’ the automaker punishes the dealership." I said I understood. "Can we do anything to enhance your customer experience?" she asked.
"Actually," I said, "you can stop badgering me with repeated customer surveys."
So, colleagues, now that you know how the pros do it, why not do likewise? Here’s how:
• Write a questionnaire that lets your customers (remember when we used to call them "patients") rate your service: ease of scheduling, courtesy of staff, promptness of appointment, appropriateness of treatment, and so on.
• Ask them to rate each on a scale of 1-5, with 5 being wonderful.
• Explain that any rating under 5 will make you very, very sad.
• Collect all questionnaires that make you very, very sad. Discard them.
• Collect all questionnaires that make you very, very happy, and – with permission, included on the questionnaire – post them on your website, Yelp, Angie’s List, and Google Reviews, indicating in each case that you are a "5-Star Doctor." (If Harvard does it, what makes you so special?)
Look for more marketing advice in future columns.
This advice is of course meant for the dwindling numbers of you who, like me, are in business for themselves. That model is basically gone. Younger colleagues will be joining large groups and institutions, whose marketing departments will take care of things like putting logos on parking-lot landings, hanging banners, and dropping leaflets on beaches in midsummer.
I will now sign off. This is Dr. Alan Rockoff. DA-DA-DA-DUMMMM!
Dr. Rockoff practices dermatology in Brookline, Mass.
A couple weeks ago I visited a nondermatologist colleague at a famous academic hospital. (Boston has many.) The floor of each landing in the parking garage was emblazoned with a message: "Highest in Customer Satisfaction!" A huge banner across the hospital’s front entrance read, "Rated #1 by U.S. News & World Report!"
The crowded lobby had a futuristic sculpture, a CVS Pharmacy, an Au Bon Pain cafe, and a franchise gift shop. Alongside a central seating area was a display of medical breakthroughs by the hospital’s staff. The lobby’s ambience felt quite similar to that of the new eastbound rest area near exit 9 on the Massachusetts Turnpike, though the highway facility has more restaurants.
Some of you may despair at hearing this. You may not have a restaurant in your waiting room, or even a Keurig coffee dispenser and flat-screen television flashing promotional announcements, as my ophthalmologist does. But fear not, dear colleagues – this columnist rides to your rescue!
Branding
I admit that I watched too much of "The Roy Rogers Show" as a kid to be able to hear the word branding without thinking cow rumps and red-hot pokers. But today you want to be not just a doctor but a brand, the way tissues are Kleenex and Google is searches. But how?
One technique large companies use is audio branding – associating their name with a short series of tones. Think of the five tinkling notes at the end of every T-Mobil commercial, or the "Ba Da Ba Ba Ba – I’m Lovin’ It!" of McDonald’s.
Because I can’t afford a composer, human or computerized, I needed something in the public domain. I got it, the first four notes of Beethoven’s Fifth Symphony. Here’s what you’ll hear on my new telephone outgoing message (and in the videos on my website): "Welcome to the office of Dr. Alan Rockoff – DA-DA-DA-DUMMMM!" Hey, it’s got pizzazz, even gravitas.
I know you’re jealous that I thought of this, but don’t even think of using it. You can have the Sixth Symphony.
Customer Satisfaction Surveys
After I took my Subaru in for a lube, oil, and filer service, the dealer sent me an e-mail customer satisfaction survey. Two days later I received a phone call reminding me that I hadn’t filled it out yet, so I did. Then I got another phone call. It would be just six questions.
"I filled out the survey already. Honest!" I said.
"On a scale of 1 to 5, with 5 being ‘excellent,’ how would you rate your experience?" asked the voice. "5!" I replied, to each of the questions. "On the survey," she continued, "you understand that for any rating less than ‘excellent,’ the automaker punishes the dealership." I said I understood. "Can we do anything to enhance your customer experience?" she asked.
"Actually," I said, "you can stop badgering me with repeated customer surveys."
So, colleagues, now that you know how the pros do it, why not do likewise? Here’s how:
• Write a questionnaire that lets your customers (remember when we used to call them "patients") rate your service: ease of scheduling, courtesy of staff, promptness of appointment, appropriateness of treatment, and so on.
• Ask them to rate each on a scale of 1-5, with 5 being wonderful.
• Explain that any rating under 5 will make you very, very sad.
• Collect all questionnaires that make you very, very sad. Discard them.
• Collect all questionnaires that make you very, very happy, and – with permission, included on the questionnaire – post them on your website, Yelp, Angie’s List, and Google Reviews, indicating in each case that you are a "5-Star Doctor." (If Harvard does it, what makes you so special?)
Look for more marketing advice in future columns.
This advice is of course meant for the dwindling numbers of you who, like me, are in business for themselves. That model is basically gone. Younger colleagues will be joining large groups and institutions, whose marketing departments will take care of things like putting logos on parking-lot landings, hanging banners, and dropping leaflets on beaches in midsummer.
I will now sign off. This is Dr. Alan Rockoff. DA-DA-DA-DUMMMM!
Dr. Rockoff practices dermatology in Brookline, Mass.
A couple weeks ago I visited a nondermatologist colleague at a famous academic hospital. (Boston has many.) The floor of each landing in the parking garage was emblazoned with a message: "Highest in Customer Satisfaction!" A huge banner across the hospital’s front entrance read, "Rated #1 by U.S. News & World Report!"
The crowded lobby had a futuristic sculpture, a CVS Pharmacy, an Au Bon Pain cafe, and a franchise gift shop. Alongside a central seating area was a display of medical breakthroughs by the hospital’s staff. The lobby’s ambience felt quite similar to that of the new eastbound rest area near exit 9 on the Massachusetts Turnpike, though the highway facility has more restaurants.
Some of you may despair at hearing this. You may not have a restaurant in your waiting room, or even a Keurig coffee dispenser and flat-screen television flashing promotional announcements, as my ophthalmologist does. But fear not, dear colleagues – this columnist rides to your rescue!
Branding
I admit that I watched too much of "The Roy Rogers Show" as a kid to be able to hear the word branding without thinking cow rumps and red-hot pokers. But today you want to be not just a doctor but a brand, the way tissues are Kleenex and Google is searches. But how?
One technique large companies use is audio branding – associating their name with a short series of tones. Think of the five tinkling notes at the end of every T-Mobil commercial, or the "Ba Da Ba Ba Ba – I’m Lovin’ It!" of McDonald’s.
Because I can’t afford a composer, human or computerized, I needed something in the public domain. I got it, the first four notes of Beethoven’s Fifth Symphony. Here’s what you’ll hear on my new telephone outgoing message (and in the videos on my website): "Welcome to the office of Dr. Alan Rockoff – DA-DA-DA-DUMMMM!" Hey, it’s got pizzazz, even gravitas.
I know you’re jealous that I thought of this, but don’t even think of using it. You can have the Sixth Symphony.
Customer Satisfaction Surveys
After I took my Subaru in for a lube, oil, and filer service, the dealer sent me an e-mail customer satisfaction survey. Two days later I received a phone call reminding me that I hadn’t filled it out yet, so I did. Then I got another phone call. It would be just six questions.
"I filled out the survey already. Honest!" I said.
"On a scale of 1 to 5, with 5 being ‘excellent,’ how would you rate your experience?" asked the voice. "5!" I replied, to each of the questions. "On the survey," she continued, "you understand that for any rating less than ‘excellent,’ the automaker punishes the dealership." I said I understood. "Can we do anything to enhance your customer experience?" she asked.
"Actually," I said, "you can stop badgering me with repeated customer surveys."
So, colleagues, now that you know how the pros do it, why not do likewise? Here’s how:
• Write a questionnaire that lets your customers (remember when we used to call them "patients") rate your service: ease of scheduling, courtesy of staff, promptness of appointment, appropriateness of treatment, and so on.
• Ask them to rate each on a scale of 1-5, with 5 being wonderful.
• Explain that any rating under 5 will make you very, very sad.
• Collect all questionnaires that make you very, very sad. Discard them.
• Collect all questionnaires that make you very, very happy, and – with permission, included on the questionnaire – post them on your website, Yelp, Angie’s List, and Google Reviews, indicating in each case that you are a "5-Star Doctor." (If Harvard does it, what makes you so special?)
Look for more marketing advice in future columns.
This advice is of course meant for the dwindling numbers of you who, like me, are in business for themselves. That model is basically gone. Younger colleagues will be joining large groups and institutions, whose marketing departments will take care of things like putting logos on parking-lot landings, hanging banners, and dropping leaflets on beaches in midsummer.
I will now sign off. This is Dr. Alan Rockoff. DA-DA-DA-DUMMMM!
Dr. Rockoff practices dermatology in Brookline, Mass.
Perspective: Incoherence
Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.
I asked Doris about her overall medical condition.
“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)
“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.
“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.
The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.
“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”
“And that didn’t help?”
“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”
They didn’t look all that swollen to me.
“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”
You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.
Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.
How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.
This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.
Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.
I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.
Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.
Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.
Dr. Alan Rockoff writes the column “Under My Skin,” which regularly appears in Skin & Allergy News, an Elsevier publication. Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].
Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.
I asked Doris about her overall medical condition.
“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)
“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.
“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.
The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.
“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”
“And that didn’t help?”
“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”
They didn’t look all that swollen to me.
“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”
You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.
Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.
How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.
This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.
Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.
I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.
Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.
Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.
Dr. Alan Rockoff writes the column “Under My Skin,” which regularly appears in Skin & Allergy News, an Elsevier publication. Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].
Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.
I asked Doris about her overall medical condition.
“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)
“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.
“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.
The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.
“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”
“And that didn’t help?”
“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”
They didn’t look all that swollen to me.
“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”
You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.
Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.
How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.
This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.
Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.
I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.
Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.
Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.
Dr. Alan Rockoff writes the column “Under My Skin,” which regularly appears in Skin & Allergy News, an Elsevier publication. Dr. Rockoff practices dermatology in Brookline, Mass. To respond to this column, e-mail him at our editorial offices at [email protected].
Incoherence
Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.
I asked Doris about her overall medical condition.
“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)
“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.
“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.
The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.
“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”
“And that didn’t help?”
“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”
They didn’t look all that swollen to me.
“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”
You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.
Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.
How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.
This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.
Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.
I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.
Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.
Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.
Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.
I asked Doris about her overall medical condition.
“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)
“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.
“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.
The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.
“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”
“And that didn’t help?”
“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”
They didn’t look all that swollen to me.
“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”
You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.
Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.
How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.
This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.
Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.
I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.
Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.
Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.
Two women came in for routine skin checks, one after the other, but as patients often prove, there was nothing “routine” about it.
I asked Doris about her overall medical condition.
“I’m feeling much better,” she said. “I had what I can only call a brain fog. I couldn’t concentrate, and I had no interest in doing any of the things I used to enjoy. I don’t know how I got it, but they diagnosed chronic Lyme disease. My doctor was at a loss. As you know, the American Medical Association doesn’t know what to do with that diagnosis.” (She said this with a smile.)
“I went to a chiropractor north of Boston. Then I found a practitioner in Vermont, and when she retired she sent me to someone else. Finally, I found an MD naturopath in Portland, Maine. He offered me two options. The first – long-term, intravenous antibiotics – didn’t sound very good, so I chose the second, a diet meant to boost my immune system. And it worked! I feel so much better. He wants me to avoid gluten, and I do, but I really love bread and pasta. So I still eat them sometimes, but not as much.
“Maybe it’s all in my head,” she mused. “Maybe I just want to think that boosting my immune system makes me feel better, but whatever the reason, the fog is gone, and I feel like myself again.” Her skin exam was normal.
The next patient was Irene, who listed her medications as etanercept and methotrexate. Seeing no obvious psoriasis, I asked what the medications were for.
“Arthritis,” she said. “I’ve been taking them for 3 years. Before that I was on adalimumab.”
“And that didn’t help?”
“It worked, I guess, but I thought maybe something else would work better. I’m not sure if the new treatment does, but I stay on it anyway. My legs are still very swollen, see?”
They didn’t look all that swollen to me.
“When I get achy, I also take ibuprofen” she said. “And I go to an acupuncturist and do yoga.”
You have to love people. (Actually, if you’re a physician you’d better.) People are so wonderfully insistent on interpreting their own symptoms and how they are doing. And they are so messy, so cheerfully incoherent.
Does Doris believe in Western medicine? Well, she’s in the office of someone who practices it. Does she believe in chiropractic medicine? Naturopathy? Yes, maybe, sometimes.
How about Irene? What is her position on acupuncture? Yoga? Does either patient know the theories behind any of these healing systems? Would pointing out the mutual incompatibility of these theories trouble Irene and Doris? Not for a moment.
This broad array of therapies is hidden from their many respective practitioners, all of whom are sure their own ministrations are working. Should they even find out their patients are using other therapies, they would probably dismiss the therapies as irrelevant.
Doris thinks she is on a gluten-free diet, sort of, but of course she does eat some bread and pasta. Practicing clergy will smile in recognition of this kind of behavior. How many of their flock have nibbled at the fruit of the gluten (it tastes good!) – only not that often and not so much (nobody’s perfect!) – without a trace of concern that backsliding implies they’ve resigned membership in the community of the faithful? Being incoherent means never having to say that noncompliance shows you’ve quit.
I love incoherence. People who insist on believing just one thing to the exclusion of all others tend to be humorless, self-righteous scolds, and are tough to deal with. I stay as far away from them as circumstances allow.
Our own medical world grows increasingly rational and bureaucratized. All is aimed at being neat, tidy, and objective: cataloging outcomes, research, and evidence-based therapies and developing meticulous, often pseudo-precise categories, such as one code for skin tags of the left eyelid and another for the right. There is something to applaud in this trend, which contributes to advancing science and discarding useless traditions.
Oh, but there is more! There has always been so much more to the practice of medicine than is dreamt of in rational, scientific pursuit of knowledge. And, whether or not anyone cares to admit it, there always will be.
Dermatologic Drama
For many years I've sent starry-eyed youths off to New York and Los Angeles to seek their fortune on Broadway or in Hollywood. I wish them luck, asking only that when they win their Tony or Oscar they remember who cleared up their skin. If their goal is to write, I ask that they pen a work starring a dermatologist.
I'm still waiting. Medicine has been fertile ground for many gripping movie and TV dramas, but these seem to center on emergency rooms, charismatic neurosurgeons, or internists with character disorders. Not a skin doctor in the bunch.
The only TV show that paid much attention to our specialty was "Seinfeld." Who can forget Jerry itching after shaving his chest hair; Jerry finding a tube of antifungal cream in his girlfriend's medicine chest; or Jerry deriding a dermatologist date as "Pimple Popper, M.D.," only to have an adjacent diner offer profound thanks for her lifesaving discovery of his melanoma?
So skin has had its moments. But no matter how we value our specialty's contribution to human happiness, we must acknowledge that the sometimes obsessive details of our daily work can play for laughs but not for pathos.
Nevertheless, I want to share the one episode in my career I can recall that did have real dramatic tension. If any reader wants to develop this incident into a TV pilot, have your people contact my people.
It happened this way: One day a friend called to say that 17-year-old Melvin was in the hospital with infections in both armpits. Oral antibiotics having failed, his physician admitted him for intravenous therapy, again with no results. The family suggested a dermatology consult, and the physician agreed. Would I come over?
Of course I would! I rarely visit hospitals anymore, but the opportunity to help out a family friend was welcome - especially since I was pretty sure I knew what he had and what to do about it. I expected no direct communication from the attending physician, and got none. I finished up at the office, drew up some Kenalog, packed alcohol pads and gauze, and headed over to the hospital.
There, I found Melvin flanked at the bedside by his anxious mother and a family friend. Both were married to physicians, raising the stakes. They explained the situation: Melvin had an infection so severe that even intravenous antibiotics had failed. What could be done?
I asked whether Melvin had ever had anything like this before. He had not. I examined him and found the expected.
I stood up and faced the family. In grave tones of reassurance and sagacity learned from reruns of "Masterpiece Theater," I said, "Melvin does not have an infection. He has hidradenitis suppurativa." This sounded more like an incantation than a diagnosis.
"Is that serious?" asked the mother.
"It can be easily treated," I explained. "In fact, I brought the treatment with me."
"But this must be a serious infection!" Melvin said. "Even IVs aren't helping."
"They aren't helping," I replied evenly, "not because you have a serious infection, but because you have no infection at all."
(Swelling violins. Cut to station break.)
After some further discussion, I convinced Melvin, his mother, and the friend that intralesional steroids were appropriate. I injected the swellings under each arm and promised to return the following day, departing to thanks tempered by anxiety. Could this exotic diagnosis with so many syllables be correct? Would the treatment actually work?
When I entered Melvin's room early the next morning, I was met with smiles of profound relief and heartfelt gratitude. The swelling was gone! The patient relieved! The unpronounceable presumption validated!
The transference in the room was thick enough to cut with a knife. I accepted the family's encomia with becoming modesty, of course, but couldn't resist the thought: How truly neat. Sure diagnosis and prompt success at the hospital bedside - by a dermatologist!
(Clashing cymbals. Cut to scenes from next week's episode.)
Well, maybe there won't be an episode next week. Though I still savor the unique circumstances of this small drama, I must admit that some medical specialties are just not cut out for prime time. But at least we're not alone.
Can you imagine "CSI: Miami, Forensic Urologists"?
Me neither.
For many years I've sent starry-eyed youths off to New York and Los Angeles to seek their fortune on Broadway or in Hollywood. I wish them luck, asking only that when they win their Tony or Oscar they remember who cleared up their skin. If their goal is to write, I ask that they pen a work starring a dermatologist.
I'm still waiting. Medicine has been fertile ground for many gripping movie and TV dramas, but these seem to center on emergency rooms, charismatic neurosurgeons, or internists with character disorders. Not a skin doctor in the bunch.
The only TV show that paid much attention to our specialty was "Seinfeld." Who can forget Jerry itching after shaving his chest hair; Jerry finding a tube of antifungal cream in his girlfriend's medicine chest; or Jerry deriding a dermatologist date as "Pimple Popper, M.D.," only to have an adjacent diner offer profound thanks for her lifesaving discovery of his melanoma?
So skin has had its moments. But no matter how we value our specialty's contribution to human happiness, we must acknowledge that the sometimes obsessive details of our daily work can play for laughs but not for pathos.
Nevertheless, I want to share the one episode in my career I can recall that did have real dramatic tension. If any reader wants to develop this incident into a TV pilot, have your people contact my people.
It happened this way: One day a friend called to say that 17-year-old Melvin was in the hospital with infections in both armpits. Oral antibiotics having failed, his physician admitted him for intravenous therapy, again with no results. The family suggested a dermatology consult, and the physician agreed. Would I come over?
Of course I would! I rarely visit hospitals anymore, but the opportunity to help out a family friend was welcome - especially since I was pretty sure I knew what he had and what to do about it. I expected no direct communication from the attending physician, and got none. I finished up at the office, drew up some Kenalog, packed alcohol pads and gauze, and headed over to the hospital.
There, I found Melvin flanked at the bedside by his anxious mother and a family friend. Both were married to physicians, raising the stakes. They explained the situation: Melvin had an infection so severe that even intravenous antibiotics had failed. What could be done?
I asked whether Melvin had ever had anything like this before. He had not. I examined him and found the expected.
I stood up and faced the family. In grave tones of reassurance and sagacity learned from reruns of "Masterpiece Theater," I said, "Melvin does not have an infection. He has hidradenitis suppurativa." This sounded more like an incantation than a diagnosis.
"Is that serious?" asked the mother.
"It can be easily treated," I explained. "In fact, I brought the treatment with me."
"But this must be a serious infection!" Melvin said. "Even IVs aren't helping."
"They aren't helping," I replied evenly, "not because you have a serious infection, but because you have no infection at all."
(Swelling violins. Cut to station break.)
After some further discussion, I convinced Melvin, his mother, and the friend that intralesional steroids were appropriate. I injected the swellings under each arm and promised to return the following day, departing to thanks tempered by anxiety. Could this exotic diagnosis with so many syllables be correct? Would the treatment actually work?
When I entered Melvin's room early the next morning, I was met with smiles of profound relief and heartfelt gratitude. The swelling was gone! The patient relieved! The unpronounceable presumption validated!
The transference in the room was thick enough to cut with a knife. I accepted the family's encomia with becoming modesty, of course, but couldn't resist the thought: How truly neat. Sure diagnosis and prompt success at the hospital bedside - by a dermatologist!
(Clashing cymbals. Cut to scenes from next week's episode.)
Well, maybe there won't be an episode next week. Though I still savor the unique circumstances of this small drama, I must admit that some medical specialties are just not cut out for prime time. But at least we're not alone.
Can you imagine "CSI: Miami, Forensic Urologists"?
Me neither.
For many years I've sent starry-eyed youths off to New York and Los Angeles to seek their fortune on Broadway or in Hollywood. I wish them luck, asking only that when they win their Tony or Oscar they remember who cleared up their skin. If their goal is to write, I ask that they pen a work starring a dermatologist.
I'm still waiting. Medicine has been fertile ground for many gripping movie and TV dramas, but these seem to center on emergency rooms, charismatic neurosurgeons, or internists with character disorders. Not a skin doctor in the bunch.
The only TV show that paid much attention to our specialty was "Seinfeld." Who can forget Jerry itching after shaving his chest hair; Jerry finding a tube of antifungal cream in his girlfriend's medicine chest; or Jerry deriding a dermatologist date as "Pimple Popper, M.D.," only to have an adjacent diner offer profound thanks for her lifesaving discovery of his melanoma?
So skin has had its moments. But no matter how we value our specialty's contribution to human happiness, we must acknowledge that the sometimes obsessive details of our daily work can play for laughs but not for pathos.
Nevertheless, I want to share the one episode in my career I can recall that did have real dramatic tension. If any reader wants to develop this incident into a TV pilot, have your people contact my people.
It happened this way: One day a friend called to say that 17-year-old Melvin was in the hospital with infections in both armpits. Oral antibiotics having failed, his physician admitted him for intravenous therapy, again with no results. The family suggested a dermatology consult, and the physician agreed. Would I come over?
Of course I would! I rarely visit hospitals anymore, but the opportunity to help out a family friend was welcome - especially since I was pretty sure I knew what he had and what to do about it. I expected no direct communication from the attending physician, and got none. I finished up at the office, drew up some Kenalog, packed alcohol pads and gauze, and headed over to the hospital.
There, I found Melvin flanked at the bedside by his anxious mother and a family friend. Both were married to physicians, raising the stakes. They explained the situation: Melvin had an infection so severe that even intravenous antibiotics had failed. What could be done?
I asked whether Melvin had ever had anything like this before. He had not. I examined him and found the expected.
I stood up and faced the family. In grave tones of reassurance and sagacity learned from reruns of "Masterpiece Theater," I said, "Melvin does not have an infection. He has hidradenitis suppurativa." This sounded more like an incantation than a diagnosis.
"Is that serious?" asked the mother.
"It can be easily treated," I explained. "In fact, I brought the treatment with me."
"But this must be a serious infection!" Melvin said. "Even IVs aren't helping."
"They aren't helping," I replied evenly, "not because you have a serious infection, but because you have no infection at all."
(Swelling violins. Cut to station break.)
After some further discussion, I convinced Melvin, his mother, and the friend that intralesional steroids were appropriate. I injected the swellings under each arm and promised to return the following day, departing to thanks tempered by anxiety. Could this exotic diagnosis with so many syllables be correct? Would the treatment actually work?
When I entered Melvin's room early the next morning, I was met with smiles of profound relief and heartfelt gratitude. The swelling was gone! The patient relieved! The unpronounceable presumption validated!
The transference in the room was thick enough to cut with a knife. I accepted the family's encomia with becoming modesty, of course, but couldn't resist the thought: How truly neat. Sure diagnosis and prompt success at the hospital bedside - by a dermatologist!
(Clashing cymbals. Cut to scenes from next week's episode.)
Well, maybe there won't be an episode next week. Though I still savor the unique circumstances of this small drama, I must admit that some medical specialties are just not cut out for prime time. But at least we're not alone.
Can you imagine "CSI: Miami, Forensic Urologists"?
Me neither.
Not Just Words, Words, Words
I was in a most undignified position: lying on a gurney in a curtained cubicle, wearing a johnny under a flimsy sheet, awaiting my 5-year colonoscopy and feeling, well, washed out. That's when I overheard a doctor's voice from the next cubicle.
"Everything looked fine, Mrs. Jenkins," said the voice. "Just some small external hemorrhoids. You might consider drinking a lot of water and eating a fiber-rich diet."
Although I'm no gastroenterologist, I know it when I hear it: verbal boilerplate. I even know it when I say it, though I try not to.
Boilerplate language is a Victorian-age metaphor. From steel sheets that could be used over and over in different machines without change came the idea of reusable units of writing – no thought needed.
We all use verbal boilerplates every day, in and out of the office. ("How's everything?" "Fine. "What's happening?" "Not much.") Verbal boilerplate has two qualities: it's delivered without much inflection, and it doesn't convey a lot of information. Of course, the second quality can be helpful. You don't really want to know how everything is, do you?
But in a professional context, boilerplate has drawbacks. The way it's delivered signals what's really going on. That's how, chilly and distracted though I was, I sensed I was hearing verbal boilerplate even before the words registered. The delivery was quieter, faster, flatter. Hemorrhoids? Press mental button: lots-of-water-fiber-rich-diet.
The second aspect, not unrelated, is that verbal boilerplate is technically correct but doesn't say much. How much water is "lots?" How much fiber is "fiber-rich?" What kind of fiber? How often?
Maybe it doesn't really matter, but that's exactly the point: when you communicate with verbal boilerplate, what you're really saying is, "I'm telling you something I'm supposed to, but whether you understand or follow my advice isn't all that important."
Such communication presents problems. The first, from a medical standpoint, is that signaling that a piece of advice isn't crucial doesn't exactly promote adherence. (Reading compliance studies is always depressing anyway.) The second, from an ordinary human perspective, is that it's deflating to ask a serious personal question – which is how patients tend to think of their concerns – and get what is in effect a canned response.
We don't like to think we dispense boilerplate, but it can be hard not to. When we see a new acne patient, how many novel and creative ways are there to present the basic spiel: no, it's not food; yes, you can use makeup; please don't pick your pimples; apply the creams and take your pills regularly; don't be discouraged if you don't clear up in 2 weeks; and, as Jerry Seinfeld might add, "Yadda yadda yadda."
The same is true for eczema, warts, or any of the routine things any dermatologist deals with daily. How tempting is it to succumb and dispense boilerplate? You've got disease X? Here is response Y. Gotta go now.
But avoiding this is indeed possible without a lot of effort or time. The first step is to recognize the problem and listen to ourselves as though we're the patient. The second is to vary the mode of presentation, even if just a bit, between one visit and the next (changing sentence order, modifying phrasing.) The third is to add emphasis to show we're making a point we really want to put across and that it does matter whether the patient understands the instructions and knows how to follow the directions. The fourth is to maintain eye contact and vary inflection to show that we are not, in fact, automated attendants giving recorded announcements with implied or explicit disclaimers, that the opinions herein expressed are not those of the management, the medical society, or the Department of Homeland Security.
Written boilerplate in a contract or lease agreement has lots of words in tiny print to show that you don't have to spend time reading it. Verbal boilerplate sends a similar message: careful listening isn't required. In that case, why bother saying it?
A week after my gurney epiphany, I got a letter from the gastroenterologist telling me I don't need another colonoscopy for 5 years. Now that's what I call meaningful communication.
I was in a most undignified position: lying on a gurney in a curtained cubicle, wearing a johnny under a flimsy sheet, awaiting my 5-year colonoscopy and feeling, well, washed out. That's when I overheard a doctor's voice from the next cubicle.
"Everything looked fine, Mrs. Jenkins," said the voice. "Just some small external hemorrhoids. You might consider drinking a lot of water and eating a fiber-rich diet."
Although I'm no gastroenterologist, I know it when I hear it: verbal boilerplate. I even know it when I say it, though I try not to.
Boilerplate language is a Victorian-age metaphor. From steel sheets that could be used over and over in different machines without change came the idea of reusable units of writing – no thought needed.
We all use verbal boilerplates every day, in and out of the office. ("How's everything?" "Fine. "What's happening?" "Not much.") Verbal boilerplate has two qualities: it's delivered without much inflection, and it doesn't convey a lot of information. Of course, the second quality can be helpful. You don't really want to know how everything is, do you?
But in a professional context, boilerplate has drawbacks. The way it's delivered signals what's really going on. That's how, chilly and distracted though I was, I sensed I was hearing verbal boilerplate even before the words registered. The delivery was quieter, faster, flatter. Hemorrhoids? Press mental button: lots-of-water-fiber-rich-diet.
The second aspect, not unrelated, is that verbal boilerplate is technically correct but doesn't say much. How much water is "lots?" How much fiber is "fiber-rich?" What kind of fiber? How often?
Maybe it doesn't really matter, but that's exactly the point: when you communicate with verbal boilerplate, what you're really saying is, "I'm telling you something I'm supposed to, but whether you understand or follow my advice isn't all that important."
Such communication presents problems. The first, from a medical standpoint, is that signaling that a piece of advice isn't crucial doesn't exactly promote adherence. (Reading compliance studies is always depressing anyway.) The second, from an ordinary human perspective, is that it's deflating to ask a serious personal question – which is how patients tend to think of their concerns – and get what is in effect a canned response.
We don't like to think we dispense boilerplate, but it can be hard not to. When we see a new acne patient, how many novel and creative ways are there to present the basic spiel: no, it's not food; yes, you can use makeup; please don't pick your pimples; apply the creams and take your pills regularly; don't be discouraged if you don't clear up in 2 weeks; and, as Jerry Seinfeld might add, "Yadda yadda yadda."
The same is true for eczema, warts, or any of the routine things any dermatologist deals with daily. How tempting is it to succumb and dispense boilerplate? You've got disease X? Here is response Y. Gotta go now.
But avoiding this is indeed possible without a lot of effort or time. The first step is to recognize the problem and listen to ourselves as though we're the patient. The second is to vary the mode of presentation, even if just a bit, between one visit and the next (changing sentence order, modifying phrasing.) The third is to add emphasis to show we're making a point we really want to put across and that it does matter whether the patient understands the instructions and knows how to follow the directions. The fourth is to maintain eye contact and vary inflection to show that we are not, in fact, automated attendants giving recorded announcements with implied or explicit disclaimers, that the opinions herein expressed are not those of the management, the medical society, or the Department of Homeland Security.
Written boilerplate in a contract or lease agreement has lots of words in tiny print to show that you don't have to spend time reading it. Verbal boilerplate sends a similar message: careful listening isn't required. In that case, why bother saying it?
A week after my gurney epiphany, I got a letter from the gastroenterologist telling me I don't need another colonoscopy for 5 years. Now that's what I call meaningful communication.
I was in a most undignified position: lying on a gurney in a curtained cubicle, wearing a johnny under a flimsy sheet, awaiting my 5-year colonoscopy and feeling, well, washed out. That's when I overheard a doctor's voice from the next cubicle.
"Everything looked fine, Mrs. Jenkins," said the voice. "Just some small external hemorrhoids. You might consider drinking a lot of water and eating a fiber-rich diet."
Although I'm no gastroenterologist, I know it when I hear it: verbal boilerplate. I even know it when I say it, though I try not to.
Boilerplate language is a Victorian-age metaphor. From steel sheets that could be used over and over in different machines without change came the idea of reusable units of writing – no thought needed.
We all use verbal boilerplates every day, in and out of the office. ("How's everything?" "Fine. "What's happening?" "Not much.") Verbal boilerplate has two qualities: it's delivered without much inflection, and it doesn't convey a lot of information. Of course, the second quality can be helpful. You don't really want to know how everything is, do you?
But in a professional context, boilerplate has drawbacks. The way it's delivered signals what's really going on. That's how, chilly and distracted though I was, I sensed I was hearing verbal boilerplate even before the words registered. The delivery was quieter, faster, flatter. Hemorrhoids? Press mental button: lots-of-water-fiber-rich-diet.
The second aspect, not unrelated, is that verbal boilerplate is technically correct but doesn't say much. How much water is "lots?" How much fiber is "fiber-rich?" What kind of fiber? How often?
Maybe it doesn't really matter, but that's exactly the point: when you communicate with verbal boilerplate, what you're really saying is, "I'm telling you something I'm supposed to, but whether you understand or follow my advice isn't all that important."
Such communication presents problems. The first, from a medical standpoint, is that signaling that a piece of advice isn't crucial doesn't exactly promote adherence. (Reading compliance studies is always depressing anyway.) The second, from an ordinary human perspective, is that it's deflating to ask a serious personal question – which is how patients tend to think of their concerns – and get what is in effect a canned response.
We don't like to think we dispense boilerplate, but it can be hard not to. When we see a new acne patient, how many novel and creative ways are there to present the basic spiel: no, it's not food; yes, you can use makeup; please don't pick your pimples; apply the creams and take your pills regularly; don't be discouraged if you don't clear up in 2 weeks; and, as Jerry Seinfeld might add, "Yadda yadda yadda."
The same is true for eczema, warts, or any of the routine things any dermatologist deals with daily. How tempting is it to succumb and dispense boilerplate? You've got disease X? Here is response Y. Gotta go now.
But avoiding this is indeed possible without a lot of effort or time. The first step is to recognize the problem and listen to ourselves as though we're the patient. The second is to vary the mode of presentation, even if just a bit, between one visit and the next (changing sentence order, modifying phrasing.) The third is to add emphasis to show we're making a point we really want to put across and that it does matter whether the patient understands the instructions and knows how to follow the directions. The fourth is to maintain eye contact and vary inflection to show that we are not, in fact, automated attendants giving recorded announcements with implied or explicit disclaimers, that the opinions herein expressed are not those of the management, the medical society, or the Department of Homeland Security.
Written boilerplate in a contract or lease agreement has lots of words in tiny print to show that you don't have to spend time reading it. Verbal boilerplate sends a similar message: careful listening isn't required. In that case, why bother saying it?
A week after my gurney epiphany, I got a letter from the gastroenterologist telling me I don't need another colonoscopy for 5 years. Now that's what I call meaningful communication.