Under My Skin

Rescue fantasies


In Walter Mitty moments, many of us daydream of glory: We’ll make that big discovery, score that disruptive app, homer in the bottom of the ninth to win the series. Then we wake up.

Dr. Alan Rockoff, a dermatologist in Brookline, Mass.

Dr. Alan Rockoff

Those of us in the helping professions have fantasies, too, though fewer as times goes by. It gets harder even to daydream that we’ll make a rare diagnosis everyone missed or cure the condition no one could. But the temptation to dream, day or night, never quite goes away. ...

Curtis is 45. He’s had eczema forever. It covers half his body. Topical steroids and courses of prednisone have failed him for decades. Maybe he’ll respond to dupilumab. Maybe his insurer will let him try.

The insurer rejects my Prior Authorization request; guidelines won’t authorize dupilumab unless the patient has failed on pimecrolimus.


I figure – what the heck – I’ll dash off a stem-winder of a letter to the insurer’s medical director.

Esteemed Director,

Like every doctor, I spend my days filling out Prior Authorization forms. These are tedious but at least make some sense on their own terms. But your rejection of dupilumab is so silly that I must object.

My patient is 6-feet tall. Half his body has been covered with eczema for a long time. No expert could possibly have told you that someone who failed oral and topical steroids would respond to pimecrolimus. Besides, how many gallons of pimecrolimus would it take to smear all over a man this size in a useless effort to show it doesn’t work?


Two days later they approved dupilumab. Triumph! Excited, I call Curtis to tell him the news.

Curtis does not respond.

My staff calls three times. He doesn’t call back.

I write Curtis a letter. Nothing.

Maybe the Prior Authorization form chased away his eczema.

Not long after Curtis, Warren comes by. In his mid-50s, Warren is miserable. “I had a responsible job,” he says. “Now I feel as though my brain is disintegrating. For the last month, I’ve had worms crawling out of my pores. ...”

I don’t know about you, dear colleagues, but nothing stirs within me a deeper sense of futility than a patient with parasitical delusions.

“Here,” says Warren, on cue, “I brought some worms in,” handing me the requisite rumpled tissue filled with squiggles of mucus.

“Look, Warren,” I say, “you’re not going to like hearing this, but there are no worms coming out of you.”

“There aren’t?”

“You think you have them, but you need help realizing you don’t. You should see a psychiatrist.”

“Really?” says Warren. “If you think it would help, that would be wonderful. Could you help me find one?”

In all my years, no patient with parasitic delusions has ever responded positively to my suggesting a psychiatric referral. Maybe I can actually help this man!

A shrink I know refers me to a colleague at TweedleDum Medical Empire, who is most cordial. “Yes,” he says, “we work closely with dermatology and handle such patients all the time. Recent symptom onset does suggest an organic cause. Have him call my appointment coordinator.”

Which I do, with great excitement. Warren is enthused too. His emails express optimism and deep gratitude, catnip to a rescue fantasist.

What follows is – not much. Warren calls me. His insurer has balked, because his primary care is at TweedleDee Medical Empire. Courtney at TweedleDum should straighten it out, but she is away. For a very long time. And so forth.

Days go by. Weeks. Emails fly back and forth. Warren wavers between hope and despair. He is waiting for Courtney. I am waiting for Godot.

I put my staff on it. Three hours later they find Courtney. In person. It’s all set!

I let Warren know. And then ...


Warren stops answering my emails. I write the cordial psychiatrist at TweedleDum.

No response.

My batting average with delusional parasitosis remains an immaculate 0.000.

Rescuing people is tricky. You need to know a bit. You need to persevere. You need contacts. You need luck.

And the patient needs to want to be rescued.

Not for nothing do they call them Rescue Fantasies.

Now I can go back to work on that disruptive app. Just wait, my friends – it’s going to disrupt the world and change everything!

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. He had no disclosures relevant to this column. Write to him at [email protected]

Next Article: