Too little vigilance.

We all have hypervigilant patients who spend too much time staring at their bodies and calling us about minor variants of normal they ought to ignore. Then there are their opposite numbers, those with what you might call hypovigilance. This term applies not just to patients but to the people around them, both in and out of the medical profession--the ones who should be saying, "Hey, take care of that!" but don't.

My parade example is the middle-aged cardiologist who came in years ago with his wife. He took off his shirt, and there, in the middle of his back, was a big melanoma. How long had the spot been there? Oh, about 3 years.

There's no problem explaining why he didn't come in sooner: It was on his back, and he's a male physician. But what about his primary doctor? (OK, maybe he does not have one.) And how about his wife? What was she thinking?

There might have been a mole there to start with, causing both wife and husband to incorporate the spot into their concept of his body image ("It's always been back there") in much the same way as people with birthmarks that others find ugly often don't have them removed because they "belong."

That explanation would not, however, work for two recent acne patients. One was a handsome 19-year-old with a 9-year history of major, scarring acne. Previous treatment? Proactiv. (Proactiv has to be the most brilliantly promoted product on the planet. How many acne patients do you see who have not used or asked about it?)

As he was saying, "You have to understand, doc. I'm a performer. I sing, I dance, I act. My face is important to me," I was thinking, "How the devil did he go 9 years without being treated or referred for this?"

Next was a 22-year-old college student, also with severe, cystic acne. She had been treated with long courses of antibiotics without sustained benefit. I broached the possibility of isotretinoin, which she thought was a fine idea because she'd researched it and several of her friends had taken it with success.

In other words, she had none of the usual fears and objections people have about this drug (depression and so on). Nobody, including the doctors who had taken care of her for several years, had ever talked to her about it. She is intelligent and acculturated, but nobody ever brought it up, and she hadn't pushed. How could this happen?

Then there was a 7-year-old girl who also came in last week with several bald scalp patches of boggy; oozing skin. This had been going on for a year. Treatment? Ketoconazole shampoo. "I think it got worse because her dad poked at it," said her mom.

Now, I haven't seen a kerion in ages, so it's not surprising that her pediatrician didn't recognize it. What I marvel at is this: Where the dickens is everybody? Why was her primary doctor willing to let this go? Where was her school nurse? Heaven knows school nurses send kids home for a lot less than this. And why has her mother not been raising an unholy ruckus to find out what the deal is with these icky bald spots instead of just blaming the dad?

I don't get it. But I see it all the time, as I'm sure you do. There might be many explanations, but the plausible ones often don't work. None of these cases involves people who lack insurance, who don't speak English, or who have cultural barriers that cause them to view Western medicine with hostility and suspicion.

We all can come up with many other examples of hypovigilance: The man who promises to come back to have an atypical mole re-excised and doesn't. The woman who's had half a dozen basal cells and agrees she should be seen every year and then returns a decade later only because she has a rash. And so on.

Many such people are, of course, beyond our control. Some will hopefully be corralled when barriers to care like unavailable health insurance are finally eliminated.

For the others, we'll just have to send a posse to go out and get 'em.

We can call them hypovigilantes.

BY ALAN ROCKOFF, M.D.

DR. ROCKOFF practices dermatology in Brookline, Mass. To respond to this column, write Dr. Rockoff at our editorial offices or e-mail him at sknews@elsevier.com.