User login
As of 2020, Dr. Rockoff began writing the quarterly column "Pruritus Emeritus."
Why do people act that way?
You can try all you want, but you never really figure people out.
Take Brendan. He spent a good few minutes chewing out my front desk staffer Linda. “You’re incompetent!” he shouted at her.
Linda tried to explain. “We can’t administer the Botox for your sweating today,” she said, “because it hasn’t come in yet.”
No, Brendan certainly didn’t want to hear that. Nor did he want to hear that we had called in advance to ask him to actually wait until we let him know that the Botox was in. But here he was, hyperinflating his lungs.
“You’re just damned useless!” he explained.
OK, we all have unreasonable patients from time to time. But what I’m describing is behavior that’s not just aggressive and unpleasant but incomprehensible. Would you like to know why I call it incomprehensible?
Because Brendan has been coming in for axillary Botox injections every 6 months for 5 years! He knows the drill. He knows the staff. He’s always pleasant as punch. Just not today. Why? Who knows?
What’s true for patients can of course also be true for employees. Model workers, superb team players, reliable folks who show up in snowstorms, who come right back to work after major surgery, who deliver heartfelt speeches at holiday parties about their good luck in overcoming adversity to be able to work. Contributors who share their pleasant disposition and can-do energy year after year ...
Until one day that they don’t show up, send a text to say they quit, no warning or explanation, then apply for Workmen’s Compensation, and at the magistrate’s hearing to which they’ve dragged my staff and our HR attorney, lie right to the face of the manager who was their best friend and confidante until the day before yesterday.
Get it? I don’t. Never will.
Two pieces of advice: 1) Don’t ever take things like that personally; and 2) Hire a good human resources attorney.
**********************
On the other hand ...
Jeralyn is 27 years old. She lists her chief complaint as “dark spots on my back.”
“How did you notice these?” I ask. “Did you see them, or did you doctor point them out?”
“It was when I tried on my wedding dress,” she says.
I understand, or think I do. Her dress exposed her back, her mother noticed the spots ...
“When is the wedding?” I ask.
“The wedding? Oh, the wedding already was. A year and a half ago.”
“You saw the spots when you tried on your wedding dress, and you’re coming in a year and half later?” I ask, trying not to sound incredulous. I’ve met enough nervous brides – and brides’ mothers – to find her account astonishing. “You must be a very patient person,” I say.
“Well,” says Jeralyn, “the spots didn’t spread or get any worse. And I am patient. I teach kindergarten. You have to be patient with little ones.”
“If you decide to have children, they’ll benefit from that,” I reply.
“That’s actually why I’m here,” says Jeralyn. “My husband and I want to start a family, and we want to be sure my skin condition wouldn’t affect that.”
A bride so unconcerned with herself that she wears a wedding dress that reveals a rash she doesn’t go running to a doctor to fix? Who comes only when the rash might affect someone else?
What is the matter with Jeralyn? Doesn’t she know she’s a millennial?
**********************
Kidding aside, wouldn’t it be nice if everyone acted like Jeralyn, and acted in a measured manner, appropriate to the concerns and circumstances? Wouldn’t it be nice if no one acted like Brendan?
That’s not how it is, though, is it? As professionals who deal with the public (as patients, coworkers, employees), we take all comers and roll with them: tolerate the annoyances and celebrate the (much larger, if less individually memorable) group who are pleasant, often delightful, sometimes inspiring.
And every once in a while, someone like Jeralyn comes along, upending all those negative expectations and reminding us that even if you can never really figure people out, it’s still worth the effort to keep trying.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
You can try all you want, but you never really figure people out.
Take Brendan. He spent a good few minutes chewing out my front desk staffer Linda. “You’re incompetent!” he shouted at her.
Linda tried to explain. “We can’t administer the Botox for your sweating today,” she said, “because it hasn’t come in yet.”
No, Brendan certainly didn’t want to hear that. Nor did he want to hear that we had called in advance to ask him to actually wait until we let him know that the Botox was in. But here he was, hyperinflating his lungs.
“You’re just damned useless!” he explained.
OK, we all have unreasonable patients from time to time. But what I’m describing is behavior that’s not just aggressive and unpleasant but incomprehensible. Would you like to know why I call it incomprehensible?
Because Brendan has been coming in for axillary Botox injections every 6 months for 5 years! He knows the drill. He knows the staff. He’s always pleasant as punch. Just not today. Why? Who knows?
What’s true for patients can of course also be true for employees. Model workers, superb team players, reliable folks who show up in snowstorms, who come right back to work after major surgery, who deliver heartfelt speeches at holiday parties about their good luck in overcoming adversity to be able to work. Contributors who share their pleasant disposition and can-do energy year after year ...
Until one day that they don’t show up, send a text to say they quit, no warning or explanation, then apply for Workmen’s Compensation, and at the magistrate’s hearing to which they’ve dragged my staff and our HR attorney, lie right to the face of the manager who was their best friend and confidante until the day before yesterday.
Get it? I don’t. Never will.
Two pieces of advice: 1) Don’t ever take things like that personally; and 2) Hire a good human resources attorney.
**********************
On the other hand ...
Jeralyn is 27 years old. She lists her chief complaint as “dark spots on my back.”
“How did you notice these?” I ask. “Did you see them, or did you doctor point them out?”
“It was when I tried on my wedding dress,” she says.
I understand, or think I do. Her dress exposed her back, her mother noticed the spots ...
“When is the wedding?” I ask.
“The wedding? Oh, the wedding already was. A year and a half ago.”
“You saw the spots when you tried on your wedding dress, and you’re coming in a year and half later?” I ask, trying not to sound incredulous. I’ve met enough nervous brides – and brides’ mothers – to find her account astonishing. “You must be a very patient person,” I say.
“Well,” says Jeralyn, “the spots didn’t spread or get any worse. And I am patient. I teach kindergarten. You have to be patient with little ones.”
“If you decide to have children, they’ll benefit from that,” I reply.
“That’s actually why I’m here,” says Jeralyn. “My husband and I want to start a family, and we want to be sure my skin condition wouldn’t affect that.”
A bride so unconcerned with herself that she wears a wedding dress that reveals a rash she doesn’t go running to a doctor to fix? Who comes only when the rash might affect someone else?
What is the matter with Jeralyn? Doesn’t she know she’s a millennial?
**********************
Kidding aside, wouldn’t it be nice if everyone acted like Jeralyn, and acted in a measured manner, appropriate to the concerns and circumstances? Wouldn’t it be nice if no one acted like Brendan?
That’s not how it is, though, is it? As professionals who deal with the public (as patients, coworkers, employees), we take all comers and roll with them: tolerate the annoyances and celebrate the (much larger, if less individually memorable) group who are pleasant, often delightful, sometimes inspiring.
And every once in a while, someone like Jeralyn comes along, upending all those negative expectations and reminding us that even if you can never really figure people out, it’s still worth the effort to keep trying.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
You can try all you want, but you never really figure people out.
Take Brendan. He spent a good few minutes chewing out my front desk staffer Linda. “You’re incompetent!” he shouted at her.
Linda tried to explain. “We can’t administer the Botox for your sweating today,” she said, “because it hasn’t come in yet.”
No, Brendan certainly didn’t want to hear that. Nor did he want to hear that we had called in advance to ask him to actually wait until we let him know that the Botox was in. But here he was, hyperinflating his lungs.
“You’re just damned useless!” he explained.
OK, we all have unreasonable patients from time to time. But what I’m describing is behavior that’s not just aggressive and unpleasant but incomprehensible. Would you like to know why I call it incomprehensible?
Because Brendan has been coming in for axillary Botox injections every 6 months for 5 years! He knows the drill. He knows the staff. He’s always pleasant as punch. Just not today. Why? Who knows?
What’s true for patients can of course also be true for employees. Model workers, superb team players, reliable folks who show up in snowstorms, who come right back to work after major surgery, who deliver heartfelt speeches at holiday parties about their good luck in overcoming adversity to be able to work. Contributors who share their pleasant disposition and can-do energy year after year ...
Until one day that they don’t show up, send a text to say they quit, no warning or explanation, then apply for Workmen’s Compensation, and at the magistrate’s hearing to which they’ve dragged my staff and our HR attorney, lie right to the face of the manager who was their best friend and confidante until the day before yesterday.
Get it? I don’t. Never will.
Two pieces of advice: 1) Don’t ever take things like that personally; and 2) Hire a good human resources attorney.
**********************
On the other hand ...
Jeralyn is 27 years old. She lists her chief complaint as “dark spots on my back.”
“How did you notice these?” I ask. “Did you see them, or did you doctor point them out?”
“It was when I tried on my wedding dress,” she says.
I understand, or think I do. Her dress exposed her back, her mother noticed the spots ...
“When is the wedding?” I ask.
“The wedding? Oh, the wedding already was. A year and a half ago.”
“You saw the spots when you tried on your wedding dress, and you’re coming in a year and half later?” I ask, trying not to sound incredulous. I’ve met enough nervous brides – and brides’ mothers – to find her account astonishing. “You must be a very patient person,” I say.
“Well,” says Jeralyn, “the spots didn’t spread or get any worse. And I am patient. I teach kindergarten. You have to be patient with little ones.”
“If you decide to have children, they’ll benefit from that,” I reply.
“That’s actually why I’m here,” says Jeralyn. “My husband and I want to start a family, and we want to be sure my skin condition wouldn’t affect that.”
A bride so unconcerned with herself that she wears a wedding dress that reveals a rash she doesn’t go running to a doctor to fix? Who comes only when the rash might affect someone else?
What is the matter with Jeralyn? Doesn’t she know she’s a millennial?
**********************
Kidding aside, wouldn’t it be nice if everyone acted like Jeralyn, and acted in a measured manner, appropriate to the concerns and circumstances? Wouldn’t it be nice if no one acted like Brendan?
That’s not how it is, though, is it? As professionals who deal with the public (as patients, coworkers, employees), we take all comers and roll with them: tolerate the annoyances and celebrate the (much larger, if less individually memorable) group who are pleasant, often delightful, sometimes inspiring.
And every once in a while, someone like Jeralyn comes along, upending all those negative expectations and reminding us that even if you can never really figure people out, it’s still worth the effort to keep trying.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Facing the world
***
Edgar is 86. His COPD recently caught up with him, and he needs oxygen. The nasal prongs that deliver it are irritating, but what really bothers him about them is that he won’t attend any activities in his assisted living facility wearing nasal prongs and trailing a tank.
***
Brenda comes in with a large bandage on her forehead. She takes it off to show me a large, jagged, fully-healed scar. Four months ago she gashed her head on an appliance and didn’t get medical help in time to have the wound properly stitched.
“My bangs aren’t thick enough to cover it,” she says. “My daughter asks why I wear a Band-Aid all the time,” says Brenda. But Brenda would rather walk around with a large bandage on her forehead. Just as Edgar won’t let anyone see him sick and diminished, Brenda won’t let anyone see her face damaged.
***
Stella has lymphoma. While she was on chemotherapy, she stayed put at home and avoided crowds to avoid catching someone’s virus. Once chemo was done, she was able to fly to Tallahassee, Fla., to see her new granddaughter Genevieve.
Unfortunately, her lymphoma recurred sooner than she and her doctors had hoped. Now Stella is on a new drug. This seems to be helping, but it puts her back at risk for infections in crowds.
And on planes. “Will you be able to visit Genevieve in Florida?” I ask.
Her husband Ben interjects. “Her doctors say she can,” he said, “but she would have to wear a mask on the plane, and Stella won’t wear a mask.”
***
Malcolm comes in now and then for this and that. This time, he is here for a skin check. At each visit he brings me up to date on an endless family lawsuit over a contested estate. Its subplots could script a whole Netflix series.
When I’m done with the skin check, Malcolm says, “also, I’d like Botox on my forehead.”
“OK,” I say. I don’t ask why, but Malcolm answers anyway.
“The lawsuit is finally coming to a head,” he says. “One of the nephews contesting the will is flying in from Indonesia, and the trial gets underway in Kentucky next week. I never would have started this fight, but since my charming relatives did, I’m in it to win it.”
I wish him luck.
“That’s why I want Botox,” he says. “I’m going to testify, and I want to look my confident best.”
Go, Malcolm!
While we’re talking Botox, I recall Amy, a well-traveled consultant who gave lectures all over.
“I’m curious,” I once asked her. “What do people say to you after you get Botox? Do they notice?”
“That’s interesting,” she said. “When I speak to groups, my face is projected onto large screens. That makes my wrinkles look like the Grand Canyon.
“When I started doing Botox, a man came over to me after a lecture and said, ‘I’ve heard you before, but this time you were, somehow, more cogent and compelling.’
“I thanked him, of course,” said Amy with a smile. “But the speech he was praising was the exact same speech he’d heard the first time.”
***
The rest of us try to put on the best face we can, assisted (in descending order of importance) by: makers of cosmetics, estheticians, dentists, plastic surgeons, and – oh yes – even dermatologists.
Happy to assist!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
***
Edgar is 86. His COPD recently caught up with him, and he needs oxygen. The nasal prongs that deliver it are irritating, but what really bothers him about them is that he won’t attend any activities in his assisted living facility wearing nasal prongs and trailing a tank.
***
Brenda comes in with a large bandage on her forehead. She takes it off to show me a large, jagged, fully-healed scar. Four months ago she gashed her head on an appliance and didn’t get medical help in time to have the wound properly stitched.
“My bangs aren’t thick enough to cover it,” she says. “My daughter asks why I wear a Band-Aid all the time,” says Brenda. But Brenda would rather walk around with a large bandage on her forehead. Just as Edgar won’t let anyone see him sick and diminished, Brenda won’t let anyone see her face damaged.
***
Stella has lymphoma. While she was on chemotherapy, she stayed put at home and avoided crowds to avoid catching someone’s virus. Once chemo was done, she was able to fly to Tallahassee, Fla., to see her new granddaughter Genevieve.
Unfortunately, her lymphoma recurred sooner than she and her doctors had hoped. Now Stella is on a new drug. This seems to be helping, but it puts her back at risk for infections in crowds.
And on planes. “Will you be able to visit Genevieve in Florida?” I ask.
Her husband Ben interjects. “Her doctors say she can,” he said, “but she would have to wear a mask on the plane, and Stella won’t wear a mask.”
***
Malcolm comes in now and then for this and that. This time, he is here for a skin check. At each visit he brings me up to date on an endless family lawsuit over a contested estate. Its subplots could script a whole Netflix series.
When I’m done with the skin check, Malcolm says, “also, I’d like Botox on my forehead.”
“OK,” I say. I don’t ask why, but Malcolm answers anyway.
“The lawsuit is finally coming to a head,” he says. “One of the nephews contesting the will is flying in from Indonesia, and the trial gets underway in Kentucky next week. I never would have started this fight, but since my charming relatives did, I’m in it to win it.”
I wish him luck.
“That’s why I want Botox,” he says. “I’m going to testify, and I want to look my confident best.”
Go, Malcolm!
While we’re talking Botox, I recall Amy, a well-traveled consultant who gave lectures all over.
“I’m curious,” I once asked her. “What do people say to you after you get Botox? Do they notice?”
“That’s interesting,” she said. “When I speak to groups, my face is projected onto large screens. That makes my wrinkles look like the Grand Canyon.
“When I started doing Botox, a man came over to me after a lecture and said, ‘I’ve heard you before, but this time you were, somehow, more cogent and compelling.’
“I thanked him, of course,” said Amy with a smile. “But the speech he was praising was the exact same speech he’d heard the first time.”
***
The rest of us try to put on the best face we can, assisted (in descending order of importance) by: makers of cosmetics, estheticians, dentists, plastic surgeons, and – oh yes – even dermatologists.
Happy to assist!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
***
Edgar is 86. His COPD recently caught up with him, and he needs oxygen. The nasal prongs that deliver it are irritating, but what really bothers him about them is that he won’t attend any activities in his assisted living facility wearing nasal prongs and trailing a tank.
***
Brenda comes in with a large bandage on her forehead. She takes it off to show me a large, jagged, fully-healed scar. Four months ago she gashed her head on an appliance and didn’t get medical help in time to have the wound properly stitched.
“My bangs aren’t thick enough to cover it,” she says. “My daughter asks why I wear a Band-Aid all the time,” says Brenda. But Brenda would rather walk around with a large bandage on her forehead. Just as Edgar won’t let anyone see him sick and diminished, Brenda won’t let anyone see her face damaged.
***
Stella has lymphoma. While she was on chemotherapy, she stayed put at home and avoided crowds to avoid catching someone’s virus. Once chemo was done, she was able to fly to Tallahassee, Fla., to see her new granddaughter Genevieve.
Unfortunately, her lymphoma recurred sooner than she and her doctors had hoped. Now Stella is on a new drug. This seems to be helping, but it puts her back at risk for infections in crowds.
And on planes. “Will you be able to visit Genevieve in Florida?” I ask.
Her husband Ben interjects. “Her doctors say she can,” he said, “but she would have to wear a mask on the plane, and Stella won’t wear a mask.”
***
Malcolm comes in now and then for this and that. This time, he is here for a skin check. At each visit he brings me up to date on an endless family lawsuit over a contested estate. Its subplots could script a whole Netflix series.
When I’m done with the skin check, Malcolm says, “also, I’d like Botox on my forehead.”
“OK,” I say. I don’t ask why, but Malcolm answers anyway.
“The lawsuit is finally coming to a head,” he says. “One of the nephews contesting the will is flying in from Indonesia, and the trial gets underway in Kentucky next week. I never would have started this fight, but since my charming relatives did, I’m in it to win it.”
I wish him luck.
“That’s why I want Botox,” he says. “I’m going to testify, and I want to look my confident best.”
Go, Malcolm!
While we’re talking Botox, I recall Amy, a well-traveled consultant who gave lectures all over.
“I’m curious,” I once asked her. “What do people say to you after you get Botox? Do they notice?”
“That’s interesting,” she said. “When I speak to groups, my face is projected onto large screens. That makes my wrinkles look like the Grand Canyon.
“When I started doing Botox, a man came over to me after a lecture and said, ‘I’ve heard you before, but this time you were, somehow, more cogent and compelling.’
“I thanked him, of course,” said Amy with a smile. “But the speech he was praising was the exact same speech he’d heard the first time.”
***
The rest of us try to put on the best face we can, assisted (in descending order of importance) by: makers of cosmetics, estheticians, dentists, plastic surgeons, and – oh yes – even dermatologists.
Happy to assist!
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Isotretinoin and shea butter
It took Jared till the end of his third month on isotretinoin to tell me he was two-timing me with another skin doctor.
“She calls herself a cosmetic dermatologist,” he said, naming a nearby practitioner I didn’t know. “She formulates special skin care products tailored to my particular skin. The one she came up with for me is based on shea butter, and it feels great.”
I am always amazed at people’s capacity to believe that there is a unique regimen just right for them, preferably one specially formulated by an expert who is privy to a secret no one else knows. Shea butter, it turns out, comes from the African shea tree (Ugandan trees are best). Africans eat the shea nuts; Westerners smear on ground-up nut contents.
Nut of shea. Tree of tea. Eye of newt. Toe of frog. The list goes on.
But I digress.
That didn’t seem very nice of her. I hadn’t murmured about her moisturizer, had I?
“What did she object to?” I asked. “Did her patients have problems with it?”
“She just said the drug is very bad,” said Jared. “She doesn’t like it at all. I was a little taken aback. I wasn’t expecting her to object so strongly.”
“But you’re still OK with taking isotretinoin?” I asked.
“Oh, yes,” said Jared. “It seems to be working, and I trust you.”
That was good to hear. I wondered whether Jared’s trust was based on the rigor of my scientific background or on my kindly smile and reassuring beard.
“Thank you, Jared,” I said. “I like isotretinoin a lot. It’s not for everybody, but for the last 35 years, I’ve seen it do excellent things for the appearance and self-image of many people.”
When I teach medical students, I often emphasize, as a point of professional etiquette, the impropriety of snorting or rolling your eyes at what patients report that other colleagues said and did. First of all, patient accounts may be imprecise or colored by their wish to build you up and flatter themselves for picking you. Second, just imagine what they might say about you at the next office they visit.
Reputation aside (you can hire folks to buff yours, if you like), my little exchange with Jared points up a basic difference between the way doctors think and the way our patients do.
What’s behind doctors’ professional lives is our assumption that diseases exist outside the bodies that the diseases inhabit. We therefore can offer a “treatment of choice” (or maybe a couple of them) that is best for treating a disease, regardless of who has it. This assumption is so obvious that we rarely think about it.
Obvious to us, that is, but not to our patients, to whom every patient has (to a large if not exclusive extent) his or her own disease. If possible, every patient wants a treatment tailored to each person’s unique makeup and predicament.
Jared is far from alone in playing both ends at the same time. From me he gets universal, evidence-based truths. From his other (more jealous!) medical mistress, he gets a skin care regimen tailored lovingly just for him.
Test your unique genes, get the treatment tailored just for you. Some rigorous scientists are trying not to so much debunk this effort as to point out how its promise is massively overhyped and unlikely to be worthy of the massive research investment it attracts. Perhaps their rigorous rationality will bear fruit, but they’re up against not just vested medical/industrial/venture capital interests, but the expectations of sick people who have always known that there is – that there simply has to be – a treatment out there that’s just for them.
Mock if you must, but tell me this: If people can prosper marketing a moisturizer called Kiss My Face or rake in the bucks with a skin care line named Urban Decay, then what’s your problem with Eye of Newt? You want focus groups?
Crowdfunding, anyone?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
It took Jared till the end of his third month on isotretinoin to tell me he was two-timing me with another skin doctor.
“She calls herself a cosmetic dermatologist,” he said, naming a nearby practitioner I didn’t know. “She formulates special skin care products tailored to my particular skin. The one she came up with for me is based on shea butter, and it feels great.”
I am always amazed at people’s capacity to believe that there is a unique regimen just right for them, preferably one specially formulated by an expert who is privy to a secret no one else knows. Shea butter, it turns out, comes from the African shea tree (Ugandan trees are best). Africans eat the shea nuts; Westerners smear on ground-up nut contents.
Nut of shea. Tree of tea. Eye of newt. Toe of frog. The list goes on.
But I digress.
That didn’t seem very nice of her. I hadn’t murmured about her moisturizer, had I?
“What did she object to?” I asked. “Did her patients have problems with it?”
“She just said the drug is very bad,” said Jared. “She doesn’t like it at all. I was a little taken aback. I wasn’t expecting her to object so strongly.”
“But you’re still OK with taking isotretinoin?” I asked.
“Oh, yes,” said Jared. “It seems to be working, and I trust you.”
That was good to hear. I wondered whether Jared’s trust was based on the rigor of my scientific background or on my kindly smile and reassuring beard.
“Thank you, Jared,” I said. “I like isotretinoin a lot. It’s not for everybody, but for the last 35 years, I’ve seen it do excellent things for the appearance and self-image of many people.”
When I teach medical students, I often emphasize, as a point of professional etiquette, the impropriety of snorting or rolling your eyes at what patients report that other colleagues said and did. First of all, patient accounts may be imprecise or colored by their wish to build you up and flatter themselves for picking you. Second, just imagine what they might say about you at the next office they visit.
Reputation aside (you can hire folks to buff yours, if you like), my little exchange with Jared points up a basic difference between the way doctors think and the way our patients do.
What’s behind doctors’ professional lives is our assumption that diseases exist outside the bodies that the diseases inhabit. We therefore can offer a “treatment of choice” (or maybe a couple of them) that is best for treating a disease, regardless of who has it. This assumption is so obvious that we rarely think about it.
Obvious to us, that is, but not to our patients, to whom every patient has (to a large if not exclusive extent) his or her own disease. If possible, every patient wants a treatment tailored to each person’s unique makeup and predicament.
Jared is far from alone in playing both ends at the same time. From me he gets universal, evidence-based truths. From his other (more jealous!) medical mistress, he gets a skin care regimen tailored lovingly just for him.
Test your unique genes, get the treatment tailored just for you. Some rigorous scientists are trying not to so much debunk this effort as to point out how its promise is massively overhyped and unlikely to be worthy of the massive research investment it attracts. Perhaps their rigorous rationality will bear fruit, but they’re up against not just vested medical/industrial/venture capital interests, but the expectations of sick people who have always known that there is – that there simply has to be – a treatment out there that’s just for them.
Mock if you must, but tell me this: If people can prosper marketing a moisturizer called Kiss My Face or rake in the bucks with a skin care line named Urban Decay, then what’s your problem with Eye of Newt? You want focus groups?
Crowdfunding, anyone?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
It took Jared till the end of his third month on isotretinoin to tell me he was two-timing me with another skin doctor.
“She calls herself a cosmetic dermatologist,” he said, naming a nearby practitioner I didn’t know. “She formulates special skin care products tailored to my particular skin. The one she came up with for me is based on shea butter, and it feels great.”
I am always amazed at people’s capacity to believe that there is a unique regimen just right for them, preferably one specially formulated by an expert who is privy to a secret no one else knows. Shea butter, it turns out, comes from the African shea tree (Ugandan trees are best). Africans eat the shea nuts; Westerners smear on ground-up nut contents.
Nut of shea. Tree of tea. Eye of newt. Toe of frog. The list goes on.
But I digress.
That didn’t seem very nice of her. I hadn’t murmured about her moisturizer, had I?
“What did she object to?” I asked. “Did her patients have problems with it?”
“She just said the drug is very bad,” said Jared. “She doesn’t like it at all. I was a little taken aback. I wasn’t expecting her to object so strongly.”
“But you’re still OK with taking isotretinoin?” I asked.
“Oh, yes,” said Jared. “It seems to be working, and I trust you.”
That was good to hear. I wondered whether Jared’s trust was based on the rigor of my scientific background or on my kindly smile and reassuring beard.
“Thank you, Jared,” I said. “I like isotretinoin a lot. It’s not for everybody, but for the last 35 years, I’ve seen it do excellent things for the appearance and self-image of many people.”
When I teach medical students, I often emphasize, as a point of professional etiquette, the impropriety of snorting or rolling your eyes at what patients report that other colleagues said and did. First of all, patient accounts may be imprecise or colored by their wish to build you up and flatter themselves for picking you. Second, just imagine what they might say about you at the next office they visit.
Reputation aside (you can hire folks to buff yours, if you like), my little exchange with Jared points up a basic difference between the way doctors think and the way our patients do.
What’s behind doctors’ professional lives is our assumption that diseases exist outside the bodies that the diseases inhabit. We therefore can offer a “treatment of choice” (or maybe a couple of them) that is best for treating a disease, regardless of who has it. This assumption is so obvious that we rarely think about it.
Obvious to us, that is, but not to our patients, to whom every patient has (to a large if not exclusive extent) his or her own disease. If possible, every patient wants a treatment tailored to each person’s unique makeup and predicament.
Jared is far from alone in playing both ends at the same time. From me he gets universal, evidence-based truths. From his other (more jealous!) medical mistress, he gets a skin care regimen tailored lovingly just for him.
Test your unique genes, get the treatment tailored just for you. Some rigorous scientists are trying not to so much debunk this effort as to point out how its promise is massively overhyped and unlikely to be worthy of the massive research investment it attracts. Perhaps their rigorous rationality will bear fruit, but they’re up against not just vested medical/industrial/venture capital interests, but the expectations of sick people who have always known that there is – that there simply has to be – a treatment out there that’s just for them.
Mock if you must, but tell me this: If people can prosper marketing a moisturizer called Kiss My Face or rake in the bucks with a skin care line named Urban Decay, then what’s your problem with Eye of Newt? You want focus groups?
Crowdfunding, anyone?
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Typhoid isn’t covered??!!
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
My wife and I decided to visit Morocco, to test the maxim that my fellow columnist Joe Eastern often cites: The words you won’t say on your deathbed are, “If only I had spent more time at the office.”
Though I’m not convinced he’s right about that – he’s never even seen my office – I thought I’d give being away a try. My office manager comes from near Marrakesh. While bound for Morocco, we could check out her hometown, even if there is no obvious tax angle.
As I contemplated exotic travel, the first things that came to mind of course were what rare diseases I might catch, which vaccines could prevent them, and how to get insurance to pay for getting immunized. Alexa helped me find CDC recommendations for immunizations for travel to Morocco, which included:
• Typhoid ... contaminated food or water.
• Hepatitis A ... contaminated food or water.
• Hepatitis B ... contaminated body fluids (sex, needles, etc.).
• Cholera ... contaminated food or water.
• Rabies ... infected animals.
• Influenza ... airborne droplets.
This trip was indeed starting to sound like an awful lot of fun.
My PCP called in several of the relevant vaccines to my local pharmacy, who informed me that typhoid vaccine is not covered by my health insurance. This spurred the following (somewhat embellished) dialogue with my insurer:
“Why is typhoid not covered?”
“Contractual exclusion. We don’t cover anything starting with “typ-,” including typhoid, typhus, typical, and typographic.”
“Do you cover bubonic plague?”
“Only for high-risk travel.”
“Such as?”
“Such as if you travel to Europe during the 14th century.”
“How about Hepatitis B and rabies?”
“That would depend.”
“On what?”
“On whether you plan to have sex with rabid bats, or rabid sex with placid bats.”
“I wouldn’t say I have plans. But, you know, in the moment ...”
“Sorry, not covered.”
“How about cholera?”
“Have you ever been threatened by cholera?
“Not exactly. But I did have a cranky uncle. When he was irritated, he often said, ‘May cholera grab you!’ ”
“You’re not covered. Your uncle might be.”
“We’ve decided on a side trip to Tanzania. As long as we’re already in Africa ...”
“Do you suffer from Sleeping Sickness?”
“Only at Grand Rounds.”
“We do cover eflornithine, but there is a problem ...”
“What problem?”
“Our only eflornithine manufacturing facility is in Bangladesh, where it takes up two floors of a factory that also makes designer jeans. That factory is closed for safety and child-labor violations.”
“For how long?”
“Indefinitely”
“Then what can I do?”
“You can apply eflornithine cream for your Sleeping Sickness and hope for the best.”
“Eflornithine cream?”
“Vaniqa. It may not help your sleeping symptoms, but you’ll need fewer haircuts.”
“Oh, thanks. What about River Blindness? Do you cover ivermectin?”
“Only if the preferred formulary alternatives have been exhausted.”
“What are those?”
“Metronidazole and azelaic acid.”
“Hold on! Are you looking at the page for onchocerciasis or the one for rosacea?”
“Yes. Did Montezuma ever make it to Morocco?”
“I don’t have that information. You’ll have to ask Alexa. Anything else?”
“No, I’m all set. Just remind me what you said about bats?”
In the end a family situation came up, and we had to cancel our trip. Instead, we watched the movie “Casablanca.” That is an excellent movie, with many pungent and memorable lines. Not only that but watching it does not cause jet lag.
As for the typhoid vaccine, in the end, it was not covered by insurance. Nevertheless, I haven’t had a bit of typhoid, so the vaccine seems to be working very well.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Educational innovation
My son’s in medical school,” Fred told me. “First year.”
“Which school?”
Fred named a newly-chartered one.
“Really innovative curriculum,” he said.
“He got into a different school, too,” he said, “but he didn’t like how that school had canceled all lectures. Students just watch the lecture videos on their devices, so they scratched all the live ones.”
“Now that they don’t need lecturers, did they cut tuition?” I asked.
We both chuckled.
I was exposed to educational innovation on Day One of medical school, in the fall of 1968. (Go ahead, do the math.) The Dean addressed our entering class. “We’ve abolished tests,” he said. “We cut preclinical study from 2 years to 18 months, followed by one comprehensive exam.
"We want to get you into the clinic right away," he said, "because you chose to be doctors to help people. Even during the preclinical period, you’ll be getting not just dry frontal teaching but exposure to actual patients.”
We guessed that sounded good, especially the part about no tests. Less day-to-day studying. A lot less.
We still had lectures, of course, on biochemistry, anatomy, and so forth (they ran out of time and did all four extremities in 1 hour), but we felt little need to pay close attention. After all, any details we’d have to memorize would be diluted over three semesters, and 18 months was so far away.
As to the lectures themselves, I’ve never been diagnosed with actual narcolepsy, but when they turned out the lights and started showing slides, I fell fast asleep. Always have.
Most of us passed the comprehensive exam and moved on to the clinic. (We didn’t get into med school without knowing how to take tests, did we?)
The basic science faculty hated this educational innovation and recognized – correctly – that without tests we would take their classes less seriously. A couple of years later, the students themselves demanded that the tests be reinstated; lack of regular, numerical feedback made them anxious. So it was back to exams every 2 weeks. Poor devils.
Fast forward 40 years. Over lunch at a friend’s house, I recently met a young woman in her second year at a medical school in Chicago. “The school has an exciting, innovative curriculum,” she told me.
“No kidding,” I said. “What’s that?”
“They want to get us into the clinic as soon as possible,” she replied. “So they cut preclinical years to 18 months. And no regular tests. Just a comprehensive exam at the end. Much less day-to-day pressure.”
“Very innovative,” I observed.
***
Once in practice, I joined the clinical faculty of a local medical school. For 35 years, I hosted senior medical students for a month-long elective. During that time, I tried to pass on some of the things that weren’t on the standard academic curriculum. For instance, that patients have their own ideas about what is wrong with them, how it got that way, and what to do about it. That medical advice is less an order than a negotiation. Students seemed to find such notions – and their daily illustrations in the office – of some interest.
I put these and related deep thoughts between the covers of a book and sent a copy to the medical school registrar, from whom I had heard little over the years unless my student evaluations were 2 days late. My cover letter suggested that the school’s educators might be curious about what I’d been teaching their charges for 35 years.
The registrar replied by e-mail. “Thank you for your book,” she wrote. “I showed it to our dean of education, who told me that we would definitely not be changing our curriculum on the basis of your book. You might contact the medical librarian to see if they want to display it.”
I didn’t recall thinking, much less saying, that my ruminations ought to overturn the medical curriculum. I just thought they might be of some passing interest, coming as they did from an outside perspective.
Not so much, it turns out.
There are, in any event, so many exciting vistas of educational innovation to develop: genomics, precision medicine, and folding doctors into health care teams, and replacing clinical judgment with algorithms. The next generation of physicians, innovatively educated, will surpass all predecessors, just as we did.
Anyhow, they'll be bound to know more about the origins and insertions of the leg muscles. They could hardly know any less.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
My son’s in medical school,” Fred told me. “First year.”
“Which school?”
Fred named a newly-chartered one.
“Really innovative curriculum,” he said.
“He got into a different school, too,” he said, “but he didn’t like how that school had canceled all lectures. Students just watch the lecture videos on their devices, so they scratched all the live ones.”
“Now that they don’t need lecturers, did they cut tuition?” I asked.
We both chuckled.
I was exposed to educational innovation on Day One of medical school, in the fall of 1968. (Go ahead, do the math.) The Dean addressed our entering class. “We’ve abolished tests,” he said. “We cut preclinical study from 2 years to 18 months, followed by one comprehensive exam.
"We want to get you into the clinic right away," he said, "because you chose to be doctors to help people. Even during the preclinical period, you’ll be getting not just dry frontal teaching but exposure to actual patients.”
We guessed that sounded good, especially the part about no tests. Less day-to-day studying. A lot less.
We still had lectures, of course, on biochemistry, anatomy, and so forth (they ran out of time and did all four extremities in 1 hour), but we felt little need to pay close attention. After all, any details we’d have to memorize would be diluted over three semesters, and 18 months was so far away.
As to the lectures themselves, I’ve never been diagnosed with actual narcolepsy, but when they turned out the lights and started showing slides, I fell fast asleep. Always have.
Most of us passed the comprehensive exam and moved on to the clinic. (We didn’t get into med school without knowing how to take tests, did we?)
The basic science faculty hated this educational innovation and recognized – correctly – that without tests we would take their classes less seriously. A couple of years later, the students themselves demanded that the tests be reinstated; lack of regular, numerical feedback made them anxious. So it was back to exams every 2 weeks. Poor devils.
Fast forward 40 years. Over lunch at a friend’s house, I recently met a young woman in her second year at a medical school in Chicago. “The school has an exciting, innovative curriculum,” she told me.
“No kidding,” I said. “What’s that?”
“They want to get us into the clinic as soon as possible,” she replied. “So they cut preclinical years to 18 months. And no regular tests. Just a comprehensive exam at the end. Much less day-to-day pressure.”
“Very innovative,” I observed.
***
Once in practice, I joined the clinical faculty of a local medical school. For 35 years, I hosted senior medical students for a month-long elective. During that time, I tried to pass on some of the things that weren’t on the standard academic curriculum. For instance, that patients have their own ideas about what is wrong with them, how it got that way, and what to do about it. That medical advice is less an order than a negotiation. Students seemed to find such notions – and their daily illustrations in the office – of some interest.
I put these and related deep thoughts between the covers of a book and sent a copy to the medical school registrar, from whom I had heard little over the years unless my student evaluations were 2 days late. My cover letter suggested that the school’s educators might be curious about what I’d been teaching their charges for 35 years.
The registrar replied by e-mail. “Thank you for your book,” she wrote. “I showed it to our dean of education, who told me that we would definitely not be changing our curriculum on the basis of your book. You might contact the medical librarian to see if they want to display it.”
I didn’t recall thinking, much less saying, that my ruminations ought to overturn the medical curriculum. I just thought they might be of some passing interest, coming as they did from an outside perspective.
Not so much, it turns out.
There are, in any event, so many exciting vistas of educational innovation to develop: genomics, precision medicine, and folding doctors into health care teams, and replacing clinical judgment with algorithms. The next generation of physicians, innovatively educated, will surpass all predecessors, just as we did.
Anyhow, they'll be bound to know more about the origins and insertions of the leg muscles. They could hardly know any less.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
My son’s in medical school,” Fred told me. “First year.”
“Which school?”
Fred named a newly-chartered one.
“Really innovative curriculum,” he said.
“He got into a different school, too,” he said, “but he didn’t like how that school had canceled all lectures. Students just watch the lecture videos on their devices, so they scratched all the live ones.”
“Now that they don’t need lecturers, did they cut tuition?” I asked.
We both chuckled.
I was exposed to educational innovation on Day One of medical school, in the fall of 1968. (Go ahead, do the math.) The Dean addressed our entering class. “We’ve abolished tests,” he said. “We cut preclinical study from 2 years to 18 months, followed by one comprehensive exam.
"We want to get you into the clinic right away," he said, "because you chose to be doctors to help people. Even during the preclinical period, you’ll be getting not just dry frontal teaching but exposure to actual patients.”
We guessed that sounded good, especially the part about no tests. Less day-to-day studying. A lot less.
We still had lectures, of course, on biochemistry, anatomy, and so forth (they ran out of time and did all four extremities in 1 hour), but we felt little need to pay close attention. After all, any details we’d have to memorize would be diluted over three semesters, and 18 months was so far away.
As to the lectures themselves, I’ve never been diagnosed with actual narcolepsy, but when they turned out the lights and started showing slides, I fell fast asleep. Always have.
Most of us passed the comprehensive exam and moved on to the clinic. (We didn’t get into med school without knowing how to take tests, did we?)
The basic science faculty hated this educational innovation and recognized – correctly – that without tests we would take their classes less seriously. A couple of years later, the students themselves demanded that the tests be reinstated; lack of regular, numerical feedback made them anxious. So it was back to exams every 2 weeks. Poor devils.
Fast forward 40 years. Over lunch at a friend’s house, I recently met a young woman in her second year at a medical school in Chicago. “The school has an exciting, innovative curriculum,” she told me.
“No kidding,” I said. “What’s that?”
“They want to get us into the clinic as soon as possible,” she replied. “So they cut preclinical years to 18 months. And no regular tests. Just a comprehensive exam at the end. Much less day-to-day pressure.”
“Very innovative,” I observed.
***
Once in practice, I joined the clinical faculty of a local medical school. For 35 years, I hosted senior medical students for a month-long elective. During that time, I tried to pass on some of the things that weren’t on the standard academic curriculum. For instance, that patients have their own ideas about what is wrong with them, how it got that way, and what to do about it. That medical advice is less an order than a negotiation. Students seemed to find such notions – and their daily illustrations in the office – of some interest.
I put these and related deep thoughts between the covers of a book and sent a copy to the medical school registrar, from whom I had heard little over the years unless my student evaluations were 2 days late. My cover letter suggested that the school’s educators might be curious about what I’d been teaching their charges for 35 years.
The registrar replied by e-mail. “Thank you for your book,” she wrote. “I showed it to our dean of education, who told me that we would definitely not be changing our curriculum on the basis of your book. You might contact the medical librarian to see if they want to display it.”
I didn’t recall thinking, much less saying, that my ruminations ought to overturn the medical curriculum. I just thought they might be of some passing interest, coming as they did from an outside perspective.
Not so much, it turns out.
There are, in any event, so many exciting vistas of educational innovation to develop: genomics, precision medicine, and folding doctors into health care teams, and replacing clinical judgment with algorithms. The next generation of physicians, innovatively educated, will surpass all predecessors, just as we did.
Anyhow, they'll be bound to know more about the origins and insertions of the leg muscles. They could hardly know any less.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Whiskey bars and Painless Parker
Have you heard of Painless Parker? A flamboyant dentist from a century ago, Parker flouted professional propriety. He wore a top hat and performed what he claimed were painless extractions on street corners, advised by a marketer who once worked for P.T. Barnum. When his dental society objected to Parker’s claims, he legally changed his first name to “Painless.”
I thought of him this week, when a southwestern colleague sent me a glossy ad from a local magazine touting a new Dermatology Cosmetic and Laser Center. It featured “a luxury men’s lounge (Man-Cave), complete with whiskey bar.”
What, asked my correspondent, is our world coming to?
Whatever that is has been coming for some time. In Parker’s day, all professional advertising was frowned upon as unseemly. That injunction seems quaint now, when drug and hospital ads flood our TV screens and pop up on every website we visit.
Medical institutions of great prestige tell the world how the techniques they employ or pioneer lead to unsurpassed outcomes, how their patient-centered focus offers compassion second to none. They post YouTube videos in which academics highlight their expertise and their team’s empathy.
I am old enough to remember when such self-promotion was thought impolite and tasteless. I am also old enough to recall when telling the universe where you’ve been and showing pictures of what you’ve been up to was considered uncouth. Few of today’s young people, hooked on Facebook and Instagram, would have any idea why on earth anybody would think such things.
Aside from the presence or prospect of physical infirmity, growing old means being baffled by new attitudes and ways of doing things that younger folks understand implicitly.
In other words, getting old means accepting that you’re out of it.
This realization suggests to me an update of the Denver Developmental Screening Test of my pediatric youth. 3 months: roll over; 6 months: sit up; 12 months: walk; 50 years: join AARP; 70 years: decry the younger generation. (“Those millennials don’t want to work hard the way we did!”)
Some of us are entering the Golden Years of The-World-is-Going-to-Hell-in-a-Handbasket.
I accept that I will not understand or appreciate social media. Younger folk don’t really care what I think about that, or anything else. Even I don’t care what I think.
Fifteen years ago, I sat late one evening in the elegant, high-ceilinged lobby of a major area medical center. A close friend was dying upstairs after a failed second liver transplant for biliary cirrhosis, the first of which had given her 10 good years.
Absorbed in thought, I leaned back and looked up. Hanging from the ceiling was a banner: “Rated Number 3 in the U.S. for Nephrology by U.S. News and World Report!”
Great, I thought. What number are they for GI?
In the nearly 40 years I’ve worked in dermatology, our field has indeed changed. Cosmetic procedures and skin care products have taken on significant, sometimes dominant roles in various settings. Some changes seem excessive at first, even shady: Botox parties in private homes? Really? With time, these come to feel normal. Man caves and whiskey bars? If the public wants them, maybe they’re the new normal.
Cole Porter wrote:
“In olden days, a glimpse of stocking
Was looked on as something shocking.
But now, God knows,
Anything goes.”
He wrote those lines 80 years ago.
Painless Parker’s self-promotion helped bring some positive changes in professional practice. Pitching to the public means that the profession cares what patients think. Back in the decorous, prudish, paternalistic old days, that was often not the case; the patient was supposed to accept whatever the experts offered and just shut up.
Trying to turn back the tide of social change is as useful as old King Canute trying to turn back the tide on the beach – an effort as pathetic as it is futile. As we age, older folks tend to become faintly ridiculous anyway. Why add negatives you can avoid?
Our office has a large exam room that’s not fully used. It contains a lightly used UVB unit.
Add comfy sofas? High-def flat-screen TVs? The NFL Network? Cigars and single-malt? What say you, colleagues?
Call me Ritzy Rockoff. It sings!
Death might not be proud, but I bet old Painless would.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Have you heard of Painless Parker? A flamboyant dentist from a century ago, Parker flouted professional propriety. He wore a top hat and performed what he claimed were painless extractions on street corners, advised by a marketer who once worked for P.T. Barnum. When his dental society objected to Parker’s claims, he legally changed his first name to “Painless.”
I thought of him this week, when a southwestern colleague sent me a glossy ad from a local magazine touting a new Dermatology Cosmetic and Laser Center. It featured “a luxury men’s lounge (Man-Cave), complete with whiskey bar.”
What, asked my correspondent, is our world coming to?
Whatever that is has been coming for some time. In Parker’s day, all professional advertising was frowned upon as unseemly. That injunction seems quaint now, when drug and hospital ads flood our TV screens and pop up on every website we visit.
Medical institutions of great prestige tell the world how the techniques they employ or pioneer lead to unsurpassed outcomes, how their patient-centered focus offers compassion second to none. They post YouTube videos in which academics highlight their expertise and their team’s empathy.
I am old enough to remember when such self-promotion was thought impolite and tasteless. I am also old enough to recall when telling the universe where you’ve been and showing pictures of what you’ve been up to was considered uncouth. Few of today’s young people, hooked on Facebook and Instagram, would have any idea why on earth anybody would think such things.
Aside from the presence or prospect of physical infirmity, growing old means being baffled by new attitudes and ways of doing things that younger folks understand implicitly.
In other words, getting old means accepting that you’re out of it.
This realization suggests to me an update of the Denver Developmental Screening Test of my pediatric youth. 3 months: roll over; 6 months: sit up; 12 months: walk; 50 years: join AARP; 70 years: decry the younger generation. (“Those millennials don’t want to work hard the way we did!”)
Some of us are entering the Golden Years of The-World-is-Going-to-Hell-in-a-Handbasket.
I accept that I will not understand or appreciate social media. Younger folk don’t really care what I think about that, or anything else. Even I don’t care what I think.
Fifteen years ago, I sat late one evening in the elegant, high-ceilinged lobby of a major area medical center. A close friend was dying upstairs after a failed second liver transplant for biliary cirrhosis, the first of which had given her 10 good years.
Absorbed in thought, I leaned back and looked up. Hanging from the ceiling was a banner: “Rated Number 3 in the U.S. for Nephrology by U.S. News and World Report!”
Great, I thought. What number are they for GI?
In the nearly 40 years I’ve worked in dermatology, our field has indeed changed. Cosmetic procedures and skin care products have taken on significant, sometimes dominant roles in various settings. Some changes seem excessive at first, even shady: Botox parties in private homes? Really? With time, these come to feel normal. Man caves and whiskey bars? If the public wants them, maybe they’re the new normal.
Cole Porter wrote:
“In olden days, a glimpse of stocking
Was looked on as something shocking.
But now, God knows,
Anything goes.”
He wrote those lines 80 years ago.
Painless Parker’s self-promotion helped bring some positive changes in professional practice. Pitching to the public means that the profession cares what patients think. Back in the decorous, prudish, paternalistic old days, that was often not the case; the patient was supposed to accept whatever the experts offered and just shut up.
Trying to turn back the tide of social change is as useful as old King Canute trying to turn back the tide on the beach – an effort as pathetic as it is futile. As we age, older folks tend to become faintly ridiculous anyway. Why add negatives you can avoid?
Our office has a large exam room that’s not fully used. It contains a lightly used UVB unit.
Add comfy sofas? High-def flat-screen TVs? The NFL Network? Cigars and single-malt? What say you, colleagues?
Call me Ritzy Rockoff. It sings!
Death might not be proud, but I bet old Painless would.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Have you heard of Painless Parker? A flamboyant dentist from a century ago, Parker flouted professional propriety. He wore a top hat and performed what he claimed were painless extractions on street corners, advised by a marketer who once worked for P.T. Barnum. When his dental society objected to Parker’s claims, he legally changed his first name to “Painless.”
I thought of him this week, when a southwestern colleague sent me a glossy ad from a local magazine touting a new Dermatology Cosmetic and Laser Center. It featured “a luxury men’s lounge (Man-Cave), complete with whiskey bar.”
What, asked my correspondent, is our world coming to?
Whatever that is has been coming for some time. In Parker’s day, all professional advertising was frowned upon as unseemly. That injunction seems quaint now, when drug and hospital ads flood our TV screens and pop up on every website we visit.
Medical institutions of great prestige tell the world how the techniques they employ or pioneer lead to unsurpassed outcomes, how their patient-centered focus offers compassion second to none. They post YouTube videos in which academics highlight their expertise and their team’s empathy.
I am old enough to remember when such self-promotion was thought impolite and tasteless. I am also old enough to recall when telling the universe where you’ve been and showing pictures of what you’ve been up to was considered uncouth. Few of today’s young people, hooked on Facebook and Instagram, would have any idea why on earth anybody would think such things.
Aside from the presence or prospect of physical infirmity, growing old means being baffled by new attitudes and ways of doing things that younger folks understand implicitly.
In other words, getting old means accepting that you’re out of it.
This realization suggests to me an update of the Denver Developmental Screening Test of my pediatric youth. 3 months: roll over; 6 months: sit up; 12 months: walk; 50 years: join AARP; 70 years: decry the younger generation. (“Those millennials don’t want to work hard the way we did!”)
Some of us are entering the Golden Years of The-World-is-Going-to-Hell-in-a-Handbasket.
I accept that I will not understand or appreciate social media. Younger folk don’t really care what I think about that, or anything else. Even I don’t care what I think.
Fifteen years ago, I sat late one evening in the elegant, high-ceilinged lobby of a major area medical center. A close friend was dying upstairs after a failed second liver transplant for biliary cirrhosis, the first of which had given her 10 good years.
Absorbed in thought, I leaned back and looked up. Hanging from the ceiling was a banner: “Rated Number 3 in the U.S. for Nephrology by U.S. News and World Report!”
Great, I thought. What number are they for GI?
In the nearly 40 years I’ve worked in dermatology, our field has indeed changed. Cosmetic procedures and skin care products have taken on significant, sometimes dominant roles in various settings. Some changes seem excessive at first, even shady: Botox parties in private homes? Really? With time, these come to feel normal. Man caves and whiskey bars? If the public wants them, maybe they’re the new normal.
Cole Porter wrote:
“In olden days, a glimpse of stocking
Was looked on as something shocking.
But now, God knows,
Anything goes.”
He wrote those lines 80 years ago.
Painless Parker’s self-promotion helped bring some positive changes in professional practice. Pitching to the public means that the profession cares what patients think. Back in the decorous, prudish, paternalistic old days, that was often not the case; the patient was supposed to accept whatever the experts offered and just shut up.
Trying to turn back the tide of social change is as useful as old King Canute trying to turn back the tide on the beach – an effort as pathetic as it is futile. As we age, older folks tend to become faintly ridiculous anyway. Why add negatives you can avoid?
Our office has a large exam room that’s not fully used. It contains a lightly used UVB unit.
Add comfy sofas? High-def flat-screen TVs? The NFL Network? Cigars and single-malt? What say you, colleagues?
Call me Ritzy Rockoff. It sings!
Death might not be proud, but I bet old Painless would.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Swiss freedom, hidden witnesses, and beer
Most of medical practice is mundane. Just a few interesting cases pass through now and then to break up the clinical routine, a rhythm that’s fine with me.
More often, patients expand my vistas by telling me about places I’ve never been and things I didn’t know and couldn’t imagine. Sometimes these tales are even more riveting than atopic dermatitis or mildly dysplastic nevi. Learning about them leaves me smiling and scratching my head. What will they tell me about next?
“I always come to Boston around this time,” she said. “But today I actually am celebrating Swiss National Day.”
“No kidding,” I said. “What is Swiss National Day?”
“We commemorate the founding of Switzerland in 1291,” she said.
“And how do you celebrate it?” I asked.
“Well, we are Swiss,” she said, “so we work all day. Then we have a party in the evening.
“That is how it used to be anyway,” she said. “About 40 years ago, the parties on the left and right made a deal and established two holidays: Labor Day on May 1st and the National Holiday on August 1st. Now we get those whole days off.”
“Which was the end of Swiss civilization as we know it,” I suggested.
“That’s exactly what my father said when it happened,” said Valentina, with a restrained, Swiss smile. “But somehow life goes on for us, even with 2 days a year off.”
* * * * * * * * * * * * * * * * * * * * * * *
When I picked up his chart, I saw that my patient’s last name suggested that he hailed from one of the countries left after the breakup of Yugoslavia. We’ll call him Magovcevic.
As soon as I walked in, however, it was clear that wherever he came from was nowhere near Serbia. His features and accent were Brazilian.
“I come from Minas Gerais,” he said, “in the South, not far from Rio.”
“So how come you have a Slavic name?” I asked him.
“My parents had a different last name,” he said.
“Then how did you come to be called Magovcevic?” I asked.
“I’m in the witness protection program,” he said.
I had to hold onto the sink to stay upright. Of all the possible responses he could have made, that one was not on my list.
“Did you pick the name yourself?” I asked. I don’t think I’d ever given a thought to how family names are chosen for people in witness protection.
“No, they gave it to me,” he said. “I was still a minor.”
At that point I stopped asking questions. Whatever it was that he witnessed as a minor that landed him in witness protection I didn’t want to know about.
* * * * * * * * * * * * * * * * * * * * * * *
Myrna was very happy to tell me that her son was doing well in college and had a good summer job.
“He works in a beer garden downtown,” she said. “The tips are great.”
“What is he studying in school?” I asked.
“Fermentation studies,” she replied.
After she’d said he was moonlighting in a beer garden, I thought she was pulling my leg. I know college students have keg parties after class, but I didn’t know they studied what goes into the kegs during class.
But Myrna was serious. “He’s interested in biochemistry,” she explained. “He wants to focus on developing better beers.”
A younger colleague whom I told about this chuckled at my perplexity. “Sure,” she said, “fermentation studies is the hot new field. Lots of people are getting into it.”
I have long since resigned myself to being clueless about what younger people are into, especially social media. But I found myself bemused at how it just never occurred to me that bright young biochemists might burn with ambition to bring the world better craft beers.
I have since learned that fermentation studies have other applications too. Like wine. And wine, like cosmetics, has been around a lot longer than dermatology.
* * * * * * * * * * * * * * * * * * * * * * *
Skin is interesting, but the people inside it are often even more so. Who knows what I’ll run into tomorrow? I won’t even try to guess.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com.
Most of medical practice is mundane. Just a few interesting cases pass through now and then to break up the clinical routine, a rhythm that’s fine with me.
More often, patients expand my vistas by telling me about places I’ve never been and things I didn’t know and couldn’t imagine. Sometimes these tales are even more riveting than atopic dermatitis or mildly dysplastic nevi. Learning about them leaves me smiling and scratching my head. What will they tell me about next?
“I always come to Boston around this time,” she said. “But today I actually am celebrating Swiss National Day.”
“No kidding,” I said. “What is Swiss National Day?”
“We commemorate the founding of Switzerland in 1291,” she said.
“And how do you celebrate it?” I asked.
“Well, we are Swiss,” she said, “so we work all day. Then we have a party in the evening.
“That is how it used to be anyway,” she said. “About 40 years ago, the parties on the left and right made a deal and established two holidays: Labor Day on May 1st and the National Holiday on August 1st. Now we get those whole days off.”
“Which was the end of Swiss civilization as we know it,” I suggested.
“That’s exactly what my father said when it happened,” said Valentina, with a restrained, Swiss smile. “But somehow life goes on for us, even with 2 days a year off.”
* * * * * * * * * * * * * * * * * * * * * * *
When I picked up his chart, I saw that my patient’s last name suggested that he hailed from one of the countries left after the breakup of Yugoslavia. We’ll call him Magovcevic.
As soon as I walked in, however, it was clear that wherever he came from was nowhere near Serbia. His features and accent were Brazilian.
“I come from Minas Gerais,” he said, “in the South, not far from Rio.”
“So how come you have a Slavic name?” I asked him.
“My parents had a different last name,” he said.
“Then how did you come to be called Magovcevic?” I asked.
“I’m in the witness protection program,” he said.
I had to hold onto the sink to stay upright. Of all the possible responses he could have made, that one was not on my list.
“Did you pick the name yourself?” I asked. I don’t think I’d ever given a thought to how family names are chosen for people in witness protection.
“No, they gave it to me,” he said. “I was still a minor.”
At that point I stopped asking questions. Whatever it was that he witnessed as a minor that landed him in witness protection I didn’t want to know about.
* * * * * * * * * * * * * * * * * * * * * * *
Myrna was very happy to tell me that her son was doing well in college and had a good summer job.
“He works in a beer garden downtown,” she said. “The tips are great.”
“What is he studying in school?” I asked.
“Fermentation studies,” she replied.
After she’d said he was moonlighting in a beer garden, I thought she was pulling my leg. I know college students have keg parties after class, but I didn’t know they studied what goes into the kegs during class.
But Myrna was serious. “He’s interested in biochemistry,” she explained. “He wants to focus on developing better beers.”
A younger colleague whom I told about this chuckled at my perplexity. “Sure,” she said, “fermentation studies is the hot new field. Lots of people are getting into it.”
I have long since resigned myself to being clueless about what younger people are into, especially social media. But I found myself bemused at how it just never occurred to me that bright young biochemists might burn with ambition to bring the world better craft beers.
I have since learned that fermentation studies have other applications too. Like wine. And wine, like cosmetics, has been around a lot longer than dermatology.
* * * * * * * * * * * * * * * * * * * * * * *
Skin is interesting, but the people inside it are often even more so. Who knows what I’ll run into tomorrow? I won’t even try to guess.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com.
Most of medical practice is mundane. Just a few interesting cases pass through now and then to break up the clinical routine, a rhythm that’s fine with me.
More often, patients expand my vistas by telling me about places I’ve never been and things I didn’t know and couldn’t imagine. Sometimes these tales are even more riveting than atopic dermatitis or mildly dysplastic nevi. Learning about them leaves me smiling and scratching my head. What will they tell me about next?
“I always come to Boston around this time,” she said. “But today I actually am celebrating Swiss National Day.”
“No kidding,” I said. “What is Swiss National Day?”
“We commemorate the founding of Switzerland in 1291,” she said.
“And how do you celebrate it?” I asked.
“Well, we are Swiss,” she said, “so we work all day. Then we have a party in the evening.
“That is how it used to be anyway,” she said. “About 40 years ago, the parties on the left and right made a deal and established two holidays: Labor Day on May 1st and the National Holiday on August 1st. Now we get those whole days off.”
“Which was the end of Swiss civilization as we know it,” I suggested.
“That’s exactly what my father said when it happened,” said Valentina, with a restrained, Swiss smile. “But somehow life goes on for us, even with 2 days a year off.”
* * * * * * * * * * * * * * * * * * * * * * *
When I picked up his chart, I saw that my patient’s last name suggested that he hailed from one of the countries left after the breakup of Yugoslavia. We’ll call him Magovcevic.
As soon as I walked in, however, it was clear that wherever he came from was nowhere near Serbia. His features and accent were Brazilian.
“I come from Minas Gerais,” he said, “in the South, not far from Rio.”
“So how come you have a Slavic name?” I asked him.
“My parents had a different last name,” he said.
“Then how did you come to be called Magovcevic?” I asked.
“I’m in the witness protection program,” he said.
I had to hold onto the sink to stay upright. Of all the possible responses he could have made, that one was not on my list.
“Did you pick the name yourself?” I asked. I don’t think I’d ever given a thought to how family names are chosen for people in witness protection.
“No, they gave it to me,” he said. “I was still a minor.”
At that point I stopped asking questions. Whatever it was that he witnessed as a minor that landed him in witness protection I didn’t want to know about.
* * * * * * * * * * * * * * * * * * * * * * *
Myrna was very happy to tell me that her son was doing well in college and had a good summer job.
“He works in a beer garden downtown,” she said. “The tips are great.”
“What is he studying in school?” I asked.
“Fermentation studies,” she replied.
After she’d said he was moonlighting in a beer garden, I thought she was pulling my leg. I know college students have keg parties after class, but I didn’t know they studied what goes into the kegs during class.
But Myrna was serious. “He’s interested in biochemistry,” she explained. “He wants to focus on developing better beers.”
A younger colleague whom I told about this chuckled at my perplexity. “Sure,” she said, “fermentation studies is the hot new field. Lots of people are getting into it.”
I have long since resigned myself to being clueless about what younger people are into, especially social media. But I found myself bemused at how it just never occurred to me that bright young biochemists might burn with ambition to bring the world better craft beers.
I have since learned that fermentation studies have other applications too. Like wine. And wine, like cosmetics, has been around a lot longer than dermatology.
* * * * * * * * * * * * * * * * * * * * * * *
Skin is interesting, but the people inside it are often even more so. Who knows what I’ll run into tomorrow? I won’t even try to guess.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com.
Consulting for the dead
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
As the years roll on, it’s nice to be open to new experiences. Till now, for instance, every patient I’ve examined has been alive.
My local hospital called 2 weeks ago. Although I’m on staff, I haven’t consulted on an inpatient there in 20 years.
I ran their skin clinic years ago. Medical residents came to my office for an elective.
“Did you see the glucagonoma on Sefton 6?” a resident would ask.
“No, they didn’t call me for that. They called me for the seborrheic dermatitis on Sefton 4.”
I no longer visit hospitals; nowadays, the main function of my hospital affiliations is to be able to see patients insured on their referral circles. This year, my hospital made a new rule: All dermatologists must cover consults to stay on staff. I drew 3 weeks in June. For 2½ weeks, nobody called. And then, late one morning …
“Hello, doctor. I’m a nurse in the medical ICU. We need your help.”
“Yes?”
“A 25-year-old man died of a drug overdose. We need to harvest his organs. He has skin changes on his back and a blister in his groin, and we need to know that these pose no bar to transplants.”
“I’m stuck in the office,“ I said. “I could come tonight.”
“Can someone else come?” he asked. “Time is critical.”
I told him I would try.
My morning session ended on time. Patient callbacks and lunch could wait. I dashed over to the hospital, phoning the nurse en route. “On my way,” I said, “but I don’t know where the ICU is, and I don’t know your protocols – what forms to fill out and so on.”
He gave me the name of the building and told me to go to the fourth floor. “We’ll have the paperwork ready,” he said.
The parking garage had a free space near the entrance. Asking directions in the lobby, I blundered my way over to the ICU building, newly built and unfamiliar, where the nurse greeted me.
“We appreciate your coming,” he said. “I’ll ask the family at the bedside to leave.”
He introduced a resident, who told me dermatologists dropped by the ICU from time to time to assess issues of graft-versus-host rashes, that sort of thing.
The nurse gave me a yellow paper gown. The patient had his own room. Back in my day, ICUs had no quiet, private spaces.
A middle-aged woman stood by the bed rail – the stepmother of the deceased. What do you say to a newly bereaved family member in this circumstance? “I am your deceased stepson’s dermatology consultant. Pleased to meet you”?
Instead, I said I was sorry for her loss, which seemed pallid but apt. She withdrew.
In bed, was a young man attached to life support. “No track marks,” the nurse observed. “He must have snorted something.”
The nurse and the resident rolled the body over, and I noted the red marks on his back. “Those are from acne,” I said. “No infection.”
Laying him down, they showed me a 1-mm scab at the base of his scrotum. “Appears to be trauma,” I said, “perhaps a scratch. Not herpes or anything infectious.”
Finding nothing else on his integument, I turned to leave. His stepmother was sitting on a chair near the door, her head in her hands. As I passed, she looked up.
In most life settings, including doctors’ offices, there are protocols of behavior, guidelines for how to act, what to say: “We’re all done.” “This should take care of it.” “I will write up a report.” “Nice to have met you.” “Take care.”
I looked down at her tortured face and said, “There is nothing to say.”
At this, I lost my composure, and left.
“I’m not sure what we were concerned about,” said the nurse, “but we appreciate your coming over.” He handed me a sheet of blank paper. I scribbled my nonfindings. Now the transplant wheels could begin to turn.
I left the ICU to its normal goings-on and returned to my office, where the paths of clinical engagement are well worn – and the patients are still alive.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
Listening for golf balls
“What did the patient say about the golf ball?” I asked my student.
The student looked blank. “Golf ball?” he asked.
“The patient said a golf ball hit him.”
“He did?”
“I showed him a precancerous red spot on his forehead, and said I could freeze it off.”
“Yes,” said the student. “Now I remember.”
“Good. Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But in his 60 years, he’s been hit by a lot of things. How can he be sure the golf ball hit just that spot? And anyhow, why tell me about it? He must have thought it was important for me to know. We discussed this the other day,” I reminded him.
“Because there was trauma?”
“That’s it,” I said. “One way patients understand why things happen to them is by saying that what got sick was hit by something. They assume trauma weakens and damages the body, and disposes it to being unhealthy.
“After all,” I went on, “I had told him his spot was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot only right there? His answer: Sun damages all skin, but the part the golf ball whacked is especially susceptible.
“Is he right? I have no idea, but it’s important – to him – to think so. Not so much for this spot – we’re going to treat it anyway – but because of what he said 2 minutes later about his left shin. Remember?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just a seborrheic keratosis, not even precancerous. But he said he was always picking it.”
“Yes, he did say that,” said the student.
“So again: Why did he think I needed to know?”
“Because picking is a form of trauma, which might cause the spot to turn into something?”
“Yes, indeed,” I said. “You should train yourself to listen to these offhand remarks that seem irrelevant to you. They are relevant to the patient, or he wouldn’t say them.
Sure enough, a little later the student and I met another patient coming for a skin check. A computer scientist from a local university, he displayed a big collection of cherry angiomas on his torso, front, and back.
Looking at his belly, he said, “I know where I got those.”
“Which ones?” I asked.
He pointed to a dense collection of red spots near his navel. “A soccer ball hit me there when I was a teenager in Colombia,” he said.
Later, the student and I discussed this man’s recollection. “What makes his observation striking,” I suggested, “is not just as another example of a patient blaming body changes on trauma. It’s that he did it in a way that even a smidgen of critical thinking – the kind he applies to his professional work all the time – would show that his hypothesis makes no sense. After all, he has dozens of red spots nowhere near where the soccer ball supposedly hit him.
“You would think a computer scientist would notice this, but when it comes to looking at our own health, even sophisticated scientific training may not help. Instead, the thinking is: “I’ve got these red spots. Something caused them. A soccer ball hit me down there. That must be it.”
Sometimes hearing what patients say doesn’t matter; we’re not going to remove the cherry angiomas. But sometimes it does, by telling us the real reason they want something removed, which may include some guilt about their own picking, guilt they can do without.
But you would have to listen for that nuance, and listening is hard. Mostly, in medicine and in life, we hear only what we expect to hear.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com
“What did the patient say about the golf ball?” I asked my student.
The student looked blank. “Golf ball?” he asked.
“The patient said a golf ball hit him.”
“He did?”
“I showed him a precancerous red spot on his forehead, and said I could freeze it off.”
“Yes,” said the student. “Now I remember.”
“Good. Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But in his 60 years, he’s been hit by a lot of things. How can he be sure the golf ball hit just that spot? And anyhow, why tell me about it? He must have thought it was important for me to know. We discussed this the other day,” I reminded him.
“Because there was trauma?”
“That’s it,” I said. “One way patients understand why things happen to them is by saying that what got sick was hit by something. They assume trauma weakens and damages the body, and disposes it to being unhealthy.
“After all,” I went on, “I had told him his spot was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot only right there? His answer: Sun damages all skin, but the part the golf ball whacked is especially susceptible.
“Is he right? I have no idea, but it’s important – to him – to think so. Not so much for this spot – we’re going to treat it anyway – but because of what he said 2 minutes later about his left shin. Remember?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just a seborrheic keratosis, not even precancerous. But he said he was always picking it.”
“Yes, he did say that,” said the student.
“So again: Why did he think I needed to know?”
“Because picking is a form of trauma, which might cause the spot to turn into something?”
“Yes, indeed,” I said. “You should train yourself to listen to these offhand remarks that seem irrelevant to you. They are relevant to the patient, or he wouldn’t say them.
Sure enough, a little later the student and I met another patient coming for a skin check. A computer scientist from a local university, he displayed a big collection of cherry angiomas on his torso, front, and back.
Looking at his belly, he said, “I know where I got those.”
“Which ones?” I asked.
He pointed to a dense collection of red spots near his navel. “A soccer ball hit me there when I was a teenager in Colombia,” he said.
Later, the student and I discussed this man’s recollection. “What makes his observation striking,” I suggested, “is not just as another example of a patient blaming body changes on trauma. It’s that he did it in a way that even a smidgen of critical thinking – the kind he applies to his professional work all the time – would show that his hypothesis makes no sense. After all, he has dozens of red spots nowhere near where the soccer ball supposedly hit him.
“You would think a computer scientist would notice this, but when it comes to looking at our own health, even sophisticated scientific training may not help. Instead, the thinking is: “I’ve got these red spots. Something caused them. A soccer ball hit me down there. That must be it.”
Sometimes hearing what patients say doesn’t matter; we’re not going to remove the cherry angiomas. But sometimes it does, by telling us the real reason they want something removed, which may include some guilt about their own picking, guilt they can do without.
But you would have to listen for that nuance, and listening is hard. Mostly, in medicine and in life, we hear only what we expect to hear.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com
“What did the patient say about the golf ball?” I asked my student.
The student looked blank. “Golf ball?” he asked.
“The patient said a golf ball hit him.”
“He did?”
“I showed him a precancerous red spot on his forehead, and said I could freeze it off.”
“Yes,” said the student. “Now I remember.”
“Good. Now tell me why he said it.”
The student looked lost. “Because he really was hit by a golf ball?”
“Maybe he was,” I said. “But in his 60 years, he’s been hit by a lot of things. How can he be sure the golf ball hit just that spot? And anyhow, why tell me about it? He must have thought it was important for me to know. We discussed this the other day,” I reminded him.
“Because there was trauma?”
“That’s it,” I said. “One way patients understand why things happen to them is by saying that what got sick was hit by something. They assume trauma weakens and damages the body, and disposes it to being unhealthy.
“After all,” I went on, “I had told him his spot was caused by sun exposure. But he’s had sun exposure all over his face, so why would he get a sun spot only right there? His answer: Sun damages all skin, but the part the golf ball whacked is especially susceptible.
“Is he right? I have no idea, but it’s important – to him – to think so. Not so much for this spot – we’re going to treat it anyway – but because of what he said 2 minutes later about his left shin. Remember?”
The student did not.
“He had a raised brown spot on his leg,” I reminded him. “It was just a seborrheic keratosis, not even precancerous. But he said he was always picking it.”
“Yes, he did say that,” said the student.
“So again: Why did he think I needed to know?”
“Because picking is a form of trauma, which might cause the spot to turn into something?”
“Yes, indeed,” I said. “You should train yourself to listen to these offhand remarks that seem irrelevant to you. They are relevant to the patient, or he wouldn’t say them.
Sure enough, a little later the student and I met another patient coming for a skin check. A computer scientist from a local university, he displayed a big collection of cherry angiomas on his torso, front, and back.
Looking at his belly, he said, “I know where I got those.”
“Which ones?” I asked.
He pointed to a dense collection of red spots near his navel. “A soccer ball hit me there when I was a teenager in Colombia,” he said.
Later, the student and I discussed this man’s recollection. “What makes his observation striking,” I suggested, “is not just as another example of a patient blaming body changes on trauma. It’s that he did it in a way that even a smidgen of critical thinking – the kind he applies to his professional work all the time – would show that his hypothesis makes no sense. After all, he has dozens of red spots nowhere near where the soccer ball supposedly hit him.
“You would think a computer scientist would notice this, but when it comes to looking at our own health, even sophisticated scientific training may not help. Instead, the thinking is: “I’ve got these red spots. Something caused them. A soccer ball hit me down there. That must be it.”
Sometimes hearing what patients say doesn’t matter; we’re not going to remove the cherry angiomas. But sometimes it does, by telling us the real reason they want something removed, which may include some guilt about their own picking, guilt they can do without.
But you would have to listen for that nuance, and listening is hard. Mostly, in medicine and in life, we hear only what we expect to hear.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com
Keep a symptom diary!
A friend sent me an article from the New Yorker called “The Algorithm Will See You Now,” in which Siddhartha Mukherjee, MD, author of the magisterial “The Emperor of All Maladies,” ponders the effect artificial intelligence may have on medicine. One possible outcome may be that computers replace radiologists and dermatologists. (They already beat top humans at Jeopardy, chess, and Go, so why not lick Homo sapiens at pattern recognition?)
No worries for me. When Watson takes over, I will be off somewhere playing shuffleboard.
“It’s a particularly bad case. But, the question is why it appeared now, and why it’s getting worse.” She asked the patient about new hair products or family stress. The man said he’d just lost his job.
“Keep a diary,” she advised. “We can determine if there’s a link.”
Thus was my pedagogic legacy shattered in an instant. I’ve spent decades advising students not to tell patients they have a bad case of anything and never to ask them to keep diaries. Then, a foremost medical writer in a leading cultural journal endorses the reverse of both lessons. What was I thinking all these years?
I counseled students not to call any case “bad” because I saw how patients took it personally if I told them that. No matter how mild their diagnosis – rosacea and seborrhea, maladies less emperors than footmen– patients who heard theirs called “bad” looked sad, even insulted. Sad and insulted patients may give up and don’t follow treatment advice. (With such a bad case, why bother?) I didn’t urge patients to think that way. I just couldn’t ignore that they did. By contrast, assuring people that their case “wasn’t bad at all!” made them light up like Halloween pumpkins.
As for diaries, I’ve filed a few that patients handed me over the years. I showed these detailed chronicles to students to illustrate the lengths to which people will go to explain the unexplainable, like the ups and downs of idiopathic urticaria, eczema, and so forth:
- Thursday, August 6th, had sushi at a restaurant with friends.
- Sunday, September 3rd, watched science-fiction movie, unable to sleep that night.
- Monday, October 2nd, discarded fourth new detergent.
And so on.
In the meantime, several times each working day patients would troop in with randomly reoccurring conditions, atopic dermatitis above all, prompting dialogues like these:
“This is crazy! I never had anything like this before!”
“Well, actually, Ms. Jones, I treated you for the same thing in 2006.”
*********************
“This is bizarre! I never had this, and no one in my family ever did either.”
“I see. Well, here’s a prescription.”
“Come to think of it, my Mom had sensitive skin, and I get these dry patches on my arms and legs every winter.”
********************
“I’ve changed my soap three times and thrown out my makeup four times, and the rash keeps coming back. What should I do?”
“Stop throwing out your soap and makeup?”
And so on and on.
Sometimes, of course, semi-plausible causes seem to surface, such as stress. The question is, How useful is it to point this out? Consider the New Yorker case. Once the doctor “determined there is a link,” how might the conversation go?
“We have found the trigger, Mr. Smith. It’s stress.”
“Great! What should I do?”
“Don’t get laid off.”
No doctor (I hope) would ever say that, but patients present reports like the following all the time:
“As a kid, I was allergic to milk, but I’m not anymore.” (No, he wasn’t – he had infantile eczema that got blamed on milk.)
“Penicillin gave me hives.” (But, the hives lasted 6 weeks after the penicillin was stopped, which showed that the hives were idiopathic.)
“I’m very sensitive. I can’t use any moisturizer, any makeup, or all pills.” (People generate long litanies of sensitivities, piling one spurious correlation on another.)
Who benefits from “determining the link” when there isn’t any? Not the patients I’ve been seeing for forty years. Your patients? Maybe detergent manufacturers?
As to my errant pedagogy, with any luck, my students don’t remember a word I told them, a safe assumption for any teacher.
Either that or they don’t read the New Yorker.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
A friend sent me an article from the New Yorker called “The Algorithm Will See You Now,” in which Siddhartha Mukherjee, MD, author of the magisterial “The Emperor of All Maladies,” ponders the effect artificial intelligence may have on medicine. One possible outcome may be that computers replace radiologists and dermatologists. (They already beat top humans at Jeopardy, chess, and Go, so why not lick Homo sapiens at pattern recognition?)
No worries for me. When Watson takes over, I will be off somewhere playing shuffleboard.
“It’s a particularly bad case. But, the question is why it appeared now, and why it’s getting worse.” She asked the patient about new hair products or family stress. The man said he’d just lost his job.
“Keep a diary,” she advised. “We can determine if there’s a link.”
Thus was my pedagogic legacy shattered in an instant. I’ve spent decades advising students not to tell patients they have a bad case of anything and never to ask them to keep diaries. Then, a foremost medical writer in a leading cultural journal endorses the reverse of both lessons. What was I thinking all these years?
I counseled students not to call any case “bad” because I saw how patients took it personally if I told them that. No matter how mild their diagnosis – rosacea and seborrhea, maladies less emperors than footmen– patients who heard theirs called “bad” looked sad, even insulted. Sad and insulted patients may give up and don’t follow treatment advice. (With such a bad case, why bother?) I didn’t urge patients to think that way. I just couldn’t ignore that they did. By contrast, assuring people that their case “wasn’t bad at all!” made them light up like Halloween pumpkins.
As for diaries, I’ve filed a few that patients handed me over the years. I showed these detailed chronicles to students to illustrate the lengths to which people will go to explain the unexplainable, like the ups and downs of idiopathic urticaria, eczema, and so forth:
- Thursday, August 6th, had sushi at a restaurant with friends.
- Sunday, September 3rd, watched science-fiction movie, unable to sleep that night.
- Monday, October 2nd, discarded fourth new detergent.
And so on.
In the meantime, several times each working day patients would troop in with randomly reoccurring conditions, atopic dermatitis above all, prompting dialogues like these:
“This is crazy! I never had anything like this before!”
“Well, actually, Ms. Jones, I treated you for the same thing in 2006.”
*********************
“This is bizarre! I never had this, and no one in my family ever did either.”
“I see. Well, here’s a prescription.”
“Come to think of it, my Mom had sensitive skin, and I get these dry patches on my arms and legs every winter.”
********************
“I’ve changed my soap three times and thrown out my makeup four times, and the rash keeps coming back. What should I do?”
“Stop throwing out your soap and makeup?”
And so on and on.
Sometimes, of course, semi-plausible causes seem to surface, such as stress. The question is, How useful is it to point this out? Consider the New Yorker case. Once the doctor “determined there is a link,” how might the conversation go?
“We have found the trigger, Mr. Smith. It’s stress.”
“Great! What should I do?”
“Don’t get laid off.”
No doctor (I hope) would ever say that, but patients present reports like the following all the time:
“As a kid, I was allergic to milk, but I’m not anymore.” (No, he wasn’t – he had infantile eczema that got blamed on milk.)
“Penicillin gave me hives.” (But, the hives lasted 6 weeks after the penicillin was stopped, which showed that the hives were idiopathic.)
“I’m very sensitive. I can’t use any moisturizer, any makeup, or all pills.” (People generate long litanies of sensitivities, piling one spurious correlation on another.)
Who benefits from “determining the link” when there isn’t any? Not the patients I’ve been seeing for forty years. Your patients? Maybe detergent manufacturers?
As to my errant pedagogy, with any luck, my students don’t remember a word I told them, a safe assumption for any teacher.
Either that or they don’t read the New Yorker.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.
A friend sent me an article from the New Yorker called “The Algorithm Will See You Now,” in which Siddhartha Mukherjee, MD, author of the magisterial “The Emperor of All Maladies,” ponders the effect artificial intelligence may have on medicine. One possible outcome may be that computers replace radiologists and dermatologists. (They already beat top humans at Jeopardy, chess, and Go, so why not lick Homo sapiens at pattern recognition?)
No worries for me. When Watson takes over, I will be off somewhere playing shuffleboard.
“It’s a particularly bad case. But, the question is why it appeared now, and why it’s getting worse.” She asked the patient about new hair products or family stress. The man said he’d just lost his job.
“Keep a diary,” she advised. “We can determine if there’s a link.”
Thus was my pedagogic legacy shattered in an instant. I’ve spent decades advising students not to tell patients they have a bad case of anything and never to ask them to keep diaries. Then, a foremost medical writer in a leading cultural journal endorses the reverse of both lessons. What was I thinking all these years?
I counseled students not to call any case “bad” because I saw how patients took it personally if I told them that. No matter how mild their diagnosis – rosacea and seborrhea, maladies less emperors than footmen– patients who heard theirs called “bad” looked sad, even insulted. Sad and insulted patients may give up and don’t follow treatment advice. (With such a bad case, why bother?) I didn’t urge patients to think that way. I just couldn’t ignore that they did. By contrast, assuring people that their case “wasn’t bad at all!” made them light up like Halloween pumpkins.
As for diaries, I’ve filed a few that patients handed me over the years. I showed these detailed chronicles to students to illustrate the lengths to which people will go to explain the unexplainable, like the ups and downs of idiopathic urticaria, eczema, and so forth:
- Thursday, August 6th, had sushi at a restaurant with friends.
- Sunday, September 3rd, watched science-fiction movie, unable to sleep that night.
- Monday, October 2nd, discarded fourth new detergent.
And so on.
In the meantime, several times each working day patients would troop in with randomly reoccurring conditions, atopic dermatitis above all, prompting dialogues like these:
“This is crazy! I never had anything like this before!”
“Well, actually, Ms. Jones, I treated you for the same thing in 2006.”
*********************
“This is bizarre! I never had this, and no one in my family ever did either.”
“I see. Well, here’s a prescription.”
“Come to think of it, my Mom had sensitive skin, and I get these dry patches on my arms and legs every winter.”
********************
“I’ve changed my soap three times and thrown out my makeup four times, and the rash keeps coming back. What should I do?”
“Stop throwing out your soap and makeup?”
And so on and on.
Sometimes, of course, semi-plausible causes seem to surface, such as stress. The question is, How useful is it to point this out? Consider the New Yorker case. Once the doctor “determined there is a link,” how might the conversation go?
“We have found the trigger, Mr. Smith. It’s stress.”
“Great! What should I do?”
“Don’t get laid off.”
No doctor (I hope) would ever say that, but patients present reports like the following all the time:
“As a kid, I was allergic to milk, but I’m not anymore.” (No, he wasn’t – he had infantile eczema that got blamed on milk.)
“Penicillin gave me hives.” (But, the hives lasted 6 weeks after the penicillin was stopped, which showed that the hives were idiopathic.)
“I’m very sensitive. I can’t use any moisturizer, any makeup, or all pills.” (People generate long litanies of sensitivities, piling one spurious correlation on another.)
Who benefits from “determining the link” when there isn’t any? Not the patients I’ve been seeing for forty years. Your patients? Maybe detergent manufacturers?
As to my errant pedagogy, with any luck, my students don’t remember a word I told them, a safe assumption for any teacher.
Either that or they don’t read the New Yorker.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at dermnews@frontlinemedcom.com.