Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler






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    Friday, September 26, 2014
     
    Basic Chili


    As an addendum to the previous post, I will tell you what I brought to the office today for lunch though I would never think of cooking it in the office (impossible, really). It's no gourmet surprise but works well enough on a busy week.


    1 lb mince (aka ground beef, ground turkey, etc)
    some chopped onion, maybe 1/2 cup or more
    1 15 oz can diced tomatoes, preferably "Mexican style" (plain is fine)
    1 15 oz can beans (pink, kidney, even black beans)
    generous amt chili powder, between 1-3 tablespoons
    shakes of cumin and garlic powder
    salt, pepper


    This is what I call good old housewife 1960's chili. And I mean that in a good way. Brown your meat, throwing in onion. Drain (if meat is not low fat). Add undrained beans, tomatoes and spices. I sometimes add some cayenne or Tabasco. Keep tasting to see if it is as you like it, simmer from 30-60 minutes. Serve with your choice of shredded cheese, chopped onion, sour cream.


    You can turn leftovers into "chili casserole" as my mother used to call it. Layer the chili in a greased casserole with tortilla chips, chopped onion and shredded cheese. (This is also known as "Mexican Lasagna"). Bake at 350 degrees till done, maybe 45 minutes. It isn't great but it isn't bad either.

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    Hands Off My Kettle!


    The food writers of the Guardian have done it again. One of their recent "Word of Mouth" blog posts deals with fixing lunch in the office. Not bringing your lunch, but cooking it in the office. The writer gives the example of using the office kettle to boil eggs in. Need I mention the primary use of said kettle is to boil water for tea? I can only imagine the sulfury, eggy taste of the first cup of tea made out of that kettle after lunch. And I'd get tired of boiled eggs for lunch awfully fast.

    As always, the comments are gold - better than the article really. I append a few.
    As I worked in a foundry, I fear my eggs would have been very hard indeed.
    According to my mother (a fount of misleading information) boiling eggs in the kettle gives you warts.
    I've been crisping bacon in the laminator and making my own pesto in the shredder for years. It makes the office smell wonderful.
    Rather than turning my pasta into tagliatelli in the shredder, we could use my pasta and your bolognese sauce to make ravioli in the laminator. Is there no end to the glory of the office lunch?
    I've converted our office water-cooler into a fermentation vat and am currently conditioning a young but surprisingly fruity Rioja.
    My jerky is nearly ready, I've had little strips of beef hanging in front of the aircon for two weeks now.

    Several comments from vegans, folks with egg allergies and those fearful of salmonella livened up the debate. I also would not be doing my blogging duty if I did not point out that the comments include a very clever ode to the George Foreman Grill. You're welcome.

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    Thursday, September 25, 2014
     
    A New Life In Total Disbelief


    Apparently, the zombie apocalypse may be upon us after all:
    Two Ebola patients, who died of the virus in separate communities in Nimba County have reportedly resurrected in the county. The victims, both females, believed to be in their 60s and 40s respectively, died of the Ebola virus recently in Hope Village Community and the Catholic Community in Ganta, Nimba. But to the amazement of residents and onlookers on Monday, the deceased reportedly regained life in total disbelief...
    The above quote came from a Liberian news site called The New Dawn. I'd like to have a chat with the author about dangling participles and such. In all seriousness, it speaks to the level of panic and lack of medical support in this epidemic that patients could be mistakenly pronounced dead - and to the amazing powers of the human body that these two women could revive after (I would assume) at least 24 hours without fluids or medical care.

    That said, if any news breaks about brain eating zombie rampages, I'm heading out to find a nice safe bunker.

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    Sunday, September 21, 2014
     
    How to Skate Around Obamacare (Maybe)


    This article appeared in the New York Times this weekend. It relates mostly to surgical fees and billing, but I found it interesting. The gist of it is that even when savvy patients go in for surgery with a surgeon they know is approved by their insurance plan, and make sure the procedure is scheduled at the hospital contracted with said plan, they can still get hit with unexpected fees if the surgeon calls in a noncontracted assistant. In many cases the assistant is in the same office as the surgeon in charge of the case. It's easy to infer that the assisting surgeon's higher fee is likely split with Surgeon #1.

    In other cases, patients reported that a hospitalist or internist who appeared on their hospital bill as rounding on them daily never in fact showed up. Or they got an echocardiogram that they didn't actually need for surgical clearance. Or other things.

    The surgeons, in many cases, blamed the hospital for the extra procedures and charges; they state that due to the drop in reimbursements this is the hospital's way of getting additional cash. As for the assistant issue, it actually is common for surgeons to have an assistant on their cases. It makes things much easier and faster in the OR to have someone retracting the edges of the wound, assisting with suturing, and so forth. My father, in fact, did this for many years on his patients. This was well before the era of managed care. His specialty was family practice, but he was deft and smart, and the surgeons loved working with him. However, he did not bill for the astronomical sums mentioned in this article; he was just an assistant, and "out of network" was not a concept that applied at that time.

    If the surgeon knows he or she is going to need an assistant on the case it is his responsibility to explain this to the patient (including exactly why one is needed) and to make sure the assistant is contracted with the patient's insurance plan. As someone who works for a large group which employs lots of staff who deal with this exact issue, I'm kind of surprised this ploy is as frequent (and successful) as it apparently is.

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    Thursday, September 18, 2014
     
    Oh, this. THIS.


    Please go and read this wonderful post right now. It's a collection of stupid comments made on food blogs and I hope it makes you as happy as it made me.

    (h/t Ace of Spades)

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    You may have noticed there has been a slight delay in posting. My apologies.  (Full disclosure: I started this post in May 2013.)

    Quite a lot has been happening. I'll try to condense it for you.

    - I once again went through the agony of recertifying in Internal Medicine. This happens every ten years and it seems to get worse every single time. The good news is that now all internists are equally discommoded by this process, instead of only those who were certified after 1990. The older doctors who were originally told that they would not have to go through this process are now stuck with it just like the rest of us. An online revolt began almost immediately; a torrent of protesting emails have been fired off to the Board and to the ACP (our academic organization for Internal Medicine). So perhaps we will finally get some relief from this torment.

    In case you are wondering about ongoing medical education, there has been a longstanding requirement for licensure that all doctors must earn a certain number of CME credits every year. The certification process has been added on top of that requirement and, in my opinion, is the board's way of grabbing control of the lucrative medical-education pie. Many doctors are threatening to let their certification expire. You can still practice without being board certified, but most medical groups and hospitals will be reluctant to hire a doctor who is not certified in some specialty. The question is, would an established physician be dismissed for letting his or her specialty certification expire? No one seems to know.

    - I turned fifty last year and celebrated it in a way I did not expect. On my birthday my mother passed out cold while walking to the refrigerator, crashed to the floor, was taken to the hospital and found to have a cardiac arrhythmia which resulted in her getting a pacemaker a week later. Fortunately she is now doing fine. But the month before my father had had a serious stroke. Add in an aunt who needed hip surgery and two cataract surgeries on my mother, and you can see it's been a very busy year.


    So what shall we talk about then? The heat wave, perhaps. It has been really warm and humid for over a week, what with two rogue hurricanes tracking up from Mexico through the Gulf of California. In Los Angeles we got little or no rain, but Nevada to the east got enough to wash out part of Interstate 15. Like many older houses on the west side, mine has no air conditioning; and because the windows are French-style that open on hinges, rather than the slide up-and-down kind, I cannot use a window unit. I dug out the giant box fan my father gave me years ago and it has been a lifesaver. It must be 40 to 50 years old and still works like a champ.

    Southern California residents are also now having to cope with the constant announcements that we are in a Drought. The Worst Drought Ever. We must save water. Well, of course we must; any fool knows that we live in a semiarid climate and the population count here is far too dense for the amount of rainfall we get. We were bound to run out of water at some point. Some years we get heavy rain and flooding, some years we get very little rain. This past winter we only had one significant storm and that was in February. California is working on desalination plants, but I think that water storage tanks in everyone's backyard to be filled during the rainy season would also be a good tactic to try. Strangely this idea has not been discussed in the local press (as far as I can tell).

    And lastly, our medical director has decided that the medical group ought to have a blog. It won't be for the public, but available on company Intranet only. I wound up being one of the doctors picked to write for it and was happy to participate, but he came up with this idea over a year ago and we still don't have the website up and running. Enduring the various delays has been somewhat frustrating, but we are told that "any day now" the blog will be functional. Uh-huh.

    The other problem regarding the work blog is that our Fearless Leader wants posts of 150 words or less. I told him that at 150 words I was just getting started. He says the idea is more to present ideas that will "foster debate" about the best methods of practice. Okay, I can see that would be educational and it will force me to stay current on topics such as vaccination recommendations, when to start treating high cholesterol levels, and so forth. But it won't be very entertaining. My idea is that after a month or so I will start mixing in a little entertainment as well. We'll see how it works.

    He doesn't know about this blog. I aim to keep it that way. I'll post more soon.

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    Saturday, September 14, 2013
     
    ZORK: THE QUEST FOR INSURANCE INFORMATION - A Text-Only Adventure Game

    > START

    > You are facing north, looking at the mouth of a cave.
    You have a walking stick.
    You have a torch.
    You have a knife.
    You have one bag of jewels.
    You have a handful of magic beans.

    > GO NORTH

    > You are in a dark cave. A woman wearing a headset is approaching you.

    > HOW MUCH IS MY DEDUCTIBLE?

    > I don't understand that.

    > QUERY DEDUCTIBLE

    > She shakes her head. "That depends on your employer," she says. "You must go back to Start."

    > GO EAST

    > You are in a maze of twisty little passages, all alike.

    > GO EAST

    > You are standing in a vast underground cavern. Many confused people are wandering around it. There is a display with numbered cards.

    > TAKE A NUMBER

    > You are number 1,752.

    > WHAT.

    > You are number --

    > YES I HEARD YOU THE FIRST TIME

    > I don't understand that.

    > USE KNIFE

    > The crowd scatters and you find yourself at the head of the line. There is a counter with computer terminals. Behind it a man is standing.

    > QUERY DEDUCTIBLE

    > He tells you your deductible is $750 per year. You have $650 left on it.

    > OH NO

    > QUERY PMD

    > He tells you that you have been reassigned to a different medical group without your prior knowledge.

    > USE MAGIC BEANS

    > You show the man your magic beans and his face lights up. After a delay of 45 minutes, he tells you that he has been able to assign you back to your original PMD.

    > QUERY COPAY

    > He tells you your copay for PMD is one bag of jewels. If you go to the ER it is three bags of jewels. Specialist: two bags of jewels.

    > FIND PMD

    > This is a quest, remember?

    > SIGH. GO NORTH

    > You are in a narrow dimly lit passage. The ground is rough here.

    > USE STICK

    > The stick helps keep you from stumbling. Suddenly as you move forward you realize the ground is opening up. Before you can react you have fallen into a large pit just ahead of you.

    > USE TORCH

    > You raise the torch above your head to see better and realize the pit is filled with... pharmaceutical representatives.

    > USE KNIFE

    > You fight them off and scramble out of the pit just in time.

    > KEEP GOING

    > You are in a maze of twisty little passages, all alike.

    > GO LEFT

    > It is pitch dark. You are likely to be eaten by a grue.

    > USE TORCH

    > You are in a chamber filled with smiling people wearing white coats.

    > QUERY PROVIDERS

    > You must be more specific.

    > QUERY PMD

    > The chamber is filled with physicians' assistants, nurse practitioners and pharmacists, all of whom are eager to help, but none of them is an MD. Do you wish to continue?

    > HMMM. GUESS I'LL CONTINUE FOR NOW. GO BACK

    > You are in a maze of twisty little passages, all alike.

    > NOT AGAIN

    > I don't understand that.

    > GO RIGHT

    > There is a light ahead of you and a trail of discarded cardboard coffee cups and donut boxes on the ground.

    > KEEP GOING

    > You are in a lighted chamber. There is a stethoscope here. There is a reflex hammer here. There is a tired looking person in a white coat here.

    > GIVE JEWELS

    > The person in the white coat is your PMD. Congratulations. You have won the game.

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    Tuesday, March 05, 2013
     
    A Really Good Headline

    As a good Stepford staff member of Tertiary Care Center, TCC's intranet web page doubles as my home page. Every morning when I fire up the box I am greeted by perky articles about the Star Safety Team Member of the Week, the latest blood drive/fundraiser/politically correct spokesperson for Disease X, or warnings about parking restrictions due to construction. There is nothing intrinsically wrong with this. It's just part of working for a big corporation (which, let's face it, I do).

    My complaint here is that whoever writes the headlines for Tertiary Care Center's intranet web page needs some remedial education. This morning the top caption reads:

    A Benign Brain Tumor, a Malignant Tumor, a Love Story and a Doctor's Reassuring Presence

    I haven't read the story, but I'm sure it is heartwarming. No doubt. Unfortunately when I read this, my twisted brain immediately produced the following:

    ...and a Partridge in a Pear Tree
    ...and Two Hard Boiled Eggs. Make That Three Hard Boiled Eggs
    ...and Six Weeks To Live

    Rewrite, people! Rewrite!

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    Thursday, February 07, 2013
     
    State of January

    Dementia is like a sinkhole. It erodes from within. Particularly with Alzheimer's, the social graces are preserved until late in the disease. You see someone who is clean, properly dressed, gracious and smiling, able to carry on a conversation - although they might seem a bit vague. It isn't until you start asking detailed questions that you begin to see what's behind the facade. What's there is a vacuum.

    Patient Gracious Lady, GL for short, has been my patient for many years. She would sometimes be brought by a family member, but often came alone. I usually see her about twice a year, as she has been in pretty good physical health. During her appointments nothing about her demeanor said dementia or struck me as unusual. She was recently hospitalized for a fairly minor problem, but the admitting MD warned me that she had been quite confused and the family member who brought her to see me for a post-discharge visit confirmed it.

    "She'll ask me a question and I answer it. Then five minutes later, she asks the same question again."

    "Who's been paying her bills? Are they getting paid?" - if you suspect dementia, this is always a good question to ask as finances are one of the first things to go by the wayside. In this case though it didn't help.

    "I'm paying them." It turned out that family members had been helping her pay her bills for the past several years. During this discussion, GL sat quietly with a calm smile on her face, divorced from the entire conversation.

    "I'm going to do something called a mini mental state exam." This is a fairly quick test which covers vocabulary, short term memory, math and orientation to place and time. It isn't perfect as even someone with early dementia will likely get the questions right. But sometimes, as today, the results can be quite striking.

    I held up a pen and she named it immediately. But when I tapped the object on her wrist and asked her to name it, it took her 45 seconds to remember that it was called a wristwatch.

    Time to test location. "What state are we in?"

    "January."

    Oh crap, I thought. Wait a minute.

    "Is it someplace like Wisconsin? Rhode Island?"

    "No, those aren't right." She pondered for a while. "It's January."

    I stole a look at the relative, who was looking pretty devastated. Every answer revealed another deficiency. To be brief, the maximal score on the MMSE is 30 points; she scored less than half that.

    There are tests that can and should be run if you suspect dementia, to rule out medical causes. You check thyroid, vitamin B12 and syphilis titers among other tests. I ordered them, but I am not really optimistic that her problem is treatable. Her MMSE score is probably too low for her to benefit from medication.

    The one blessing that I have seen in dementia is that the patients themselves don't seem to be aware that they have a problem - or if they are aware, it doesn't really bother them. When a patient comes in with a complaint of "I keep forgetting things and I'm really worried that I have a problem," you can almost guarantee that they are not dementing. It's when the family or friends bring the patient in that you have to be concerned. GL had that same calm, detached air. The good news is that she has caring family who will look after her, and I firmly believe that social interaction helps in this disease.  Still, it is not something that one would ever wish for a relative or loved one.

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    Sunday, February 03, 2013
     
    Perfecto!


    I say, Your Majesty, you know how to handle a weapon. Rumor has it Jack Bauer took lessons from you.

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    Saturday, February 02, 2013
     
    On Children

    Sometimes patients will bring their children to their appointments - this usually means they are very young children and that the parents couldn't make arrangements for the kids. It doesn't bother me. In fact, on a tough day it invigorates me to have a baby in the room. My favorite trick for the young ones is to hand them a tongue depressor; it is wonderful to see them eyeing it, grasping it with both hands (what is this? I imagine them thinking) and then, of course, eventually gnawing on it.

    I also remember one energetic two-year-old who entertained himself by opening the bottom drawer of the exam table and taking out, one by one, the small plastic jars of  preservative fluid contained therein. The jars are for Pap smears. Don't worry, they were safely sealed and there was no way he could have opened them. The worried father asked if this was a problem. "As long as he's not screaming, I'm happy," I reassured him.

    The older ones find it interesting to look over my shoulder as I'm typing and especially to look at pictures of X rays. Or sometimes they will just stare at me, The Doctor, as I interview and examine their parent. Or they may even ask questions, which I love. Rarely a child will announce that he or she wants to be a doctor and I encourage them heartily.

    Pediatrics, though, I could not do. I realized that as a medical student the first night a neonate came in with a fever and we had to do a spinal tap on the infant. Now that my office is right next to the Pediatrics Department and I hear the wails of children echoing through the air vent on a regular basis, I am even more certain I made the right choice.

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    Monday, January 28, 2013
     
    Flu B Gone

    The flu has hit. Some years it's not so bad, some years it's worse. We don't have tents out in the parking lot or anything, but it sure has been busy around here. Today my suitemate and two nurses are out and I have the feeling it's going to be a bad day... a long, bad day.

    On those days you grasp at anything to cheer yourself up. Like today, when I was ordering antiviral for yet another patient down with influenza and typed "Tamifly" instead of Tamiflu. (That's oseltamivir for you pedants out there.) Doesn't that sound like a much cooler name? A whole marketing campaign sprang to life in my head, fully formed.

    Don't be flu. Be fly. With Tamifly.
    Fly above the flu. Tamifly can help you too!

    More coffee. I need more coffee...

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    Saturday, January 05, 2013
     
    "As God Is My Witness, I'll Never Go Hungry Again!" Said the Dieter

    So I'm counseling a patient on weight loss. She mentioned that she goes to a fair number of social functions and has to eat what she's served there; which is often a problem.

    "You could always do a Scarlett O'Hara and eat before you go," I suggested.

    She looked blank. "Huh?"

    "Surely you know your Gone With the Wind?" She didn't.

    "Well, early in the book Scarlett O'Hara is getting ready to go to a barbecue at a plantation nearby. Apparently in those days ladies weren't supposed to have an appetite, or to eat much in public. So she eats a whole meal before she goes to the barbecue. Then she gets there, and the host is serving wonderful food that nobody's eating, and it's just like Beverly Hills!"

    She laughed with delighted recognition. That she got. And if I'm lucky, I may have even inspired her to read Gone With the Wind. (If you haven't, do give it a try; it combines the best qualities of the soap opera and the historical novel.)


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    Wednesday, September 26, 2012
     
    "I Look Forward to Your Next Article, 'How to Breathe'"

    I have come to enjoy reading the Guardian's "Word of Mouth" food articles (for a conservative, this is akin to explaining that you read Playboy for the interviews). One writer, Tony Naylor, has a series titled "How to Eat" various food items (i.e., what is your favorite way to serve a hamburger?) Today's article may have hit a new low, however:

    How To Eat Breakfast Cereal

    Dear Lord, Tony. I may not be at my best in the morning, but give me a little credit. Do read the comments: they are hilarious. The title for this post is taken from one of them.

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    Tuesday, August 28, 2012
     
    The British have a real talent for desserts. (Have you noticed this?) I may be more prone to their charms because of my UK heritage, or because I'm not a chocoholic. Most traditional Anglo desserts aren't based on chocolate. Or because I think everything goes better with gravy - the dessert variation is a baked or steamed dessert with a sauce on top. As a med student many years ago I wangled my way into a plastic surgery rotation at Oxford, and whenever the hospital canteen served rhubarb crumble with custard sauce I was the happiest camper in town. Yes, the custard was lumpy and made from Bird's dessert powder, but even so.

    Though I adore it, trifle may not be to everyone's taste... but if you haven't tasted sticky toffee pudding, put it on your bucket list. Yes, it is that good. Steamed desserts like Spotted Dick (it has currants in it, and in Britain it comes in a can. No, really) and sticky toffee pudding are good but best reserved for cold weather. Not to worry, the Brits excel at summer desserts too. They pioneered the class of desserts known as "fools," usually a mixture of fruit and cream, chilled. The fruit can be cooked as in gooseberry fools, or raw, crushed and macerated with sugar, such as raspberry fools. You whip the cream, chill the fruit, and mix the two together.

    A variant of this idea is Eton Mess. The name comes, I think, from the fact that the schoolboys at Eton would mash everything on the dessert plate together with their spoons and then eat it. It sounds unappetizing but it is really delicious. It is now past high strawberry season and I should have posted this earlier, but here we go. The recipe is made easier by the existence of Trader Joes, which sells vanilla meringues in large plastic buckets. If you don't have a TJ's near you, you may be forced to make your own, or look around at any local specialty stores.

    Ingredients are simple: strawberries, meringues, whipping cream. You will use equal parts of each. Crush the meringues, but not too finely. Mix with sliced strawberries and whipped cream. Let chill for a little while, maybe half an hour, and eat. You want the meringue to still be a little crunchy. Yum.

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    Thursday, August 23, 2012
     
    "I won't quit smoking"
    You said, after the tumor
    You died yesterday.

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