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“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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    Monday, October 26, 2015
    There Was No Gilligan, But There Was a Mysterious Dude.

    I was converted to the concept of the e-reader (eBook, whatever) by my roommate on my Guatemala trip several years ago. Another busy physician, her specialty was family practice and we bonded over finally having the time to read without guilt, since there was nothing else to do in the evenings after the clinic closed for the day. She was glued to her Kindle every night. I was jealous that she never seemed to run out of reading material, whereas I zipped through my book and two magazines in nothing flat.

    So when I got home I knuckled under and bought one. At first I wondered if I would ever download enough to justify the purchase, but that really has not been a problem. Have I bought more books? Yes, I have. But did you know that there are a lot of free books available for the Kindle? Yes, free. FREE. If you subscribe to Amazon Prime it gives you access to the Amazon Library system; there are a ton of books that you can obtain on loan. The limit is one per month, but if you are an avid mystery reader it's great to have access to all the paperback cozies you want without having to spend $7.95 on a book you'll never read again.

    (Incidentally, what is it with mysteries these days? When did cozies start to incorporate recipes, scrapbooking, witchcraft, knitting and God knows what? I still read them, all right, but I'm starting to hate myself. The heroine/detective usually spends more time enthusing over her cats or her latest yarn purchase than she does solving the crime. I mean, Philip Marlowe would NEVER.)

    But back to Free. I had heard that there was a big self-publishing market on Kindle, but I didn't realize how big until I started reading a prepper/homesteading blog in which the author used to publish a daily list of free books available on Kindle. I'd link to it, but the author then made the list available by subscription only. The books focus on topics of interest to preppers and homesteaders, such as homeschooling, working from home, religion, food storage, agriculture, etc. I have downloaded some of them, all of which were self-published, and the quality varies widely. Some are better than others.

    But then I thought: What if I just type in 'free' on my Kindle? I tried it, and realized that on any given day there are thousands of free books available. Many of them are classics which some deserving soul has laboriously transcribed into a Kindle compatible format. Jane Eyre, Pride and Prejudice, Tom Sawyer - I felt as though someone had set me loose in a candy store and told me to grab everything I wanted.

    And that is how I came to be reading Jules Verne's The Mysterious Island.

    I love Jules Verne. Around the World in Eighty Days is still one of my favorite books, and one of my daydreams is to someday take three months off to go around the world. I also loved Captain Nemo, the self-exiled main character of 20,000 Leagues Under the Sea. Mysterious Island (published 1874) is commonly called the sequel to 20,000 Leagues, but that's not all it is by a long shot. I would rather call it a stand-alone novel which incorporates a character from his previous novel. Verne started with this premise: if a group of people are marooned on an island with nothing but fortitude, knowledge and the clothes on their backs, can they survive?

     The book is set in 1865 and focuses on a group of Americans, prisoners of war in Richmond, Virginia (they are Yankees). They escape from Richmond via a hot-air balloon which I guess someone carelessly left sitting around, are caught up in a storm over the open ocean and are forced to throw everything they own out of the balloon to reduce its weight before eventually crashing on an island. Captain Cyrus, the leader of the group, is an engineer; the other characters include his servant, a free black named Neb; Pencroft (a sailor); Herbert (the teenage ward of Pencroft whose hobby is natural history); and a journalist named Gideon.

    It's interesting to read the book from a twenty-first century perspective. Our heroes have no qualms about exploiting every resource they can lay their hands on. They even wind up dynamiting part of the island to form an indoor shelter (it's a large undersea cavern, and the explosion allows them to drain part of the water out). The island just happens to contain clay, iron ore, nitrites, etc. etc. and the engineer figures out how to smelt the ore, build a kiln to make pottery and so forth. One running joke is that Pencroft is constantly hungry. Every time they find a new species, his question is: "Can you eat it?" Environmentalists everywhere would scream reading this book.

    When the group initially lands on the island, of course, they have absolutely nothing. One of their group gets into trouble and then is mysteriously rescued; then they discover a chest of clothing and supplies sitting on the beach. Pretty soon they figure out that they aren't alone on the island...

    The Mysterious Island is a good read, though somewhat stiff by today's standards. The adventure parts are interspersed with pages of straight-up chemistry whereby the engineer explains how the group is going to make gunpowder, why he knows the island contains iron ore and so on, which absolutely kills the suspense. But you can skim these parts. It's kind of like reading Tom Clancy where you blip over the parts describing tanks and aircraft in loving detail.

    To get back to my initial point, I've been completely converted to the concept of e-readers. I continue to buy and read print books, and I don't think print will ever go away - nor should it. But the equipment is inexpensive and lasts a long time. I've had my Kindle for four years and it's still going strong. It's an older model to be sure, but I have not felt the need to purchase a new one. If you have been considering the purchase, or have bought one but aren't sure what to do with it, the free options alone are worth it in my opinion. Give it a shot.

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    Friday, October 23, 2015
    Nine Days Later

    Well. Dad got through the aortic valve procedure okay, I am glad to say. The one-week follow up did not go so well. I don't want to throw in too much detail but he had a lot of swelling and pain which developed after he was discharged from the hospital. He of course did not share this with anyone, including my mother, until the night before the appointment. He insisted on wearing an old pair of scrubs to this appointment, as he could not put on a pair of pants - but he could not tie the scrubs and his pants kept falling down. (I sent an urgent memo to my mother to get him some sweat pants ASAP.)

    He had to have a lot of neurologic testing done that day which further delayed us, and the cardiologist who had presided over the AV replacement wanted him to have an ultrasound. Long story short, we did not get home until after 9 pm, at which point my mother realized that she had lost the key to her car.

    So I drove the 30 miles or so to their home and picked up the spare key, then drove back, then realized I had lost my cell phone.

    That was the worst day by far. The rest of the summer was still pretty hairy, but nothing like as bad. While all this was going on, one of my co-workers was out of the office due to a severe illness of a family member; add all this up and you can probably see why I have not posted in a while.

    But it's fall now, things seem much better and I'm going to leave it at that. It's time to get back to my usual ramblings.

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    Thursday, October 22, 2015
    Horse Manure! (It's Therapeutic!)

    I invite you to read this eye-opening article run by the New Yorker some time back about therapy animals. It's truly ridiculous what people can get away with these days. I found the article entertaining, as I have run into similar requests at work.

    About a year ago in my office my partner was confronted by a therapy rat. Yes, a rat. The rat was in a bag around the patient's neck and it perched on her shoulder while she was having her blood pressure taken. I give the medical assistant credit for not shrieking during this process. After a hasty discussion with risk management the rat was placed into the patient's mother's custody and evicted to the hallway. Legally speaking, the only formally recognized service animals are dogs and miniature horses. ("You mean ponies?" I asked. "No, miniature horses" was the reply.)

    I have gotten my fair share of requests to write letters allowing patients to take their pets - they are not service animals - just about anywhere. I usually decline, unless the patient has a known psychiatric or medical issue which really requires taking the animal with them. If it's psychiatric, they need to be seeing, or to have seen, a psychiatrist. It bugs the heck out of me when I see people playing the system like this.

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    Wednesday, June 24, 2015
    Plunged Into Caregiving

    About four months ago my mother asked me to call my father's cardiologist to get clarification on something - "He wants us to do some testing. Is this really necessary?" So I did.

    "Your father has aortic stenosis," the cardiologist said without preamble (he knows I'm an MD), "and it's pretty significant."

    My attitude when we opened the conversation had been doctor-to-doctor. Now suddenly all that vanished and I was repeating, in a very small voice, "Dad has aortic stenosis?"

    The gist of the conversation: yes he did, and furthermore it was getting worse, and the cardiologist wanted to do an angiogram. One angiogram later, Dad had a stent in his right coronary artery but still no clear word on the valve. Cardiologist #1 suggested that we see his pal, Cardiologist #2, an expert in aortic valve problems. By a stroke of luck #2 works at my hospital, Tertiary Care Medical Center.

    This guy is hardcore. He has a large office in the very newest building on the hospital campus. Each room has a chair that looks a bit like a recliner, which doubles as a scale. Yes, they press a button and the chair raises a few inches off the ground and they weigh the patient sitting in the chair. He also has a fleet of nurse practitioners and technicians, high grade office equipment and the ability to perform echocardiograms in the exam rooms. The tech clearly knew what he was doing but still could not get a clear picture of Dad's valve. He pressed a button on the room's intercom, ordered a bag of contrast and this was infused through a vein, right in the exam room, by a nurse who appeared out of nowhere.

    It's wonderful what money can buy. I guarantee you that no internist or primary care doctor has facilities like this.

    After this, we found that the AS was really quite bad indeed. Dad needed a valve replacement as soon as possible. We all agreed that the traditional method (aka "cracking the chest") was not a good idea as Dad is not in the best medical condition. He has a history of several strokes and some dementia. Cardiologist #2 specializes in valve replacement via the femoral artery. How he does this I have no idea, but overall it is less stressful and risky than open chest valve replacement.

    Today we go for the final round of preoperative assessments and tests. He is having more of a workup than average because he's been entered into a study wherein the surgeon places a filter in the aortic arch before doing the valve replacement, which should lessen the risk of additional strokes. Tomorrow, if all goes well, he has the procedure.

    I have been in charge since the workup started: transport to the hospital, spending the night in the hospital with Dad postprocedure and translating developments to the rest of the family. I now really empathize with patients who get confused and lost, and who complain about having to go to the doctor all the time; I am learning exactly how that feels. As you can imagine, I've had to do some canceling and reworking of my office schedule, but I really don't care. All I want is for this to work.

    Wish us luck.

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    Tuesday, May 05, 2015
    Not My Best Week

    Another wildly insane day is under my belt. It's hard to say exactly why I left the office feeling so jittery and tense. It may have been the phone call that turned into a 30 minute conversation with a worried son of a new patient. It may have been my current patient who has lost her insurance and now is on Medicaid, which means that for some mysterious reason several of her medications are no longer being covered; suddenly the pharmacy is demanding authorization requests for even the most basic of medications.

    It may have been the new patient I saw today who turned out to have multiple unforeseen issues. This particular patient discontinued their diabetes medication three years before and then proceeded not to seek medical care for three years. Today this person turned out to have a random blood sugar of 311. Surprise!

    It doesn't help that I am still jetlagged. This past weekend I attended the ACP annual conference. This year it was held in Boston. I did not have the luxury of extra time to adjust to the three-hour time difference between Los Angeles and Boston either going or coming. The conference was good and I think I learned quite a bit, but it is very hard to get spoonfed lectures for 10 hours a day for three days running without losing your mind. No exaggeration; the lectures start at seven in the morning and run until 5:30 PM (with breaks, of course).

    And there is more. Two weeks ago my father's cardiologist decided that he needed a catheterization to evaluate his aortic valve. The valve turned out to be functioning reasonably okay but he had a stenosis in his right coronary artery which required a stent placement. This meant that he had to spend the night in the hospital. Guess who spent the night with him? Yes, it was I. I was somewhat philosophical about this turn of events until I was told by the nursing staff that they have no arrangements made for family to spend the night with patients. This meant that I slept in two chairs, continually getting up to remind my father that no, he could not get out of bed to go to the bathroom.

    This week I learned that two of our physicians will be taking medical leave somewhat urgently. I don't know the cause and I don't need to know. What I do know is that their patients have to go somewhere, and they will be distributed among the rest of us. Is it any wonder that I am giving serious thought to running away screaming?

    I don't have a good way to end this jumble of thoughts. Consider it a therapeutic brain dump. I will be back soon, hopefully in a better mood.

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    Saturday, March 21, 2015
    So Bad It's... Bad. 

    Ladies and gentlemen, I am proud to announce the return of Workout Movie Theater. In this ongoing series I review fragments of film I have caught on the elliptical or treadmill while at the gym. (Yes, I belong to one of those chichi gyms that have television screens attached to the workout equipment.)

    Today's film is Con Air, an action-adventure film from 1997. I like to think of the nineties as the golden era of crap action movies, possibly because that was the last decade when I actually had time to go to the movies. This film is outstandingly, memorably bad, not least because the cast is really very good. If only Arnold Schwarzenegger had been in it it would have been perfect. It's based on an actual federal air transport system used to move convicts and illegal aliens across the country. You don't have to be psychic to predict the plot: the criminals take over the plane and wreak havoc. Needless to say we've got a good guy on board who tries to take down the criminals.

    So far so good. Things start to unravel when you realize that the hero is played by Nicholas Cage, who has clad himself in a wifebeater T-shirt and Southern accent for this film. He's supposed to be a former Army Ranger from Alabama who went to jail for manslaughter committed when he was trying to protect his pregnant wife from assault. He's been in jail for seven years and has never seen his kid. Why he wound up on a plane with a bunch of mad serial killers I have no idea (I missed the start of the movie). The cast includes John Malkovich (chewing the scenery as the head bad guy), Steve Buscemi as a serial killer who really doesn't seem so bad compared to Malkovich's character, Colm Meaney (aka "the Irish guy from Star Trek") as a DEA agent, and John Cusack, who looks about twelve, as a U.S. Marshal. (I understand Cusack hates this film so much that he refuses to talk about it in interviews. I can't say I blame him.)

    So. With a cast like this, why is it so bad? Let's list the reasons.

    • Language. Not only do we have F-bonbs galore, we have more gratuitous racist insults than you would believe. In the setting of a plane full of convicts, half black and half white, I would have expected to hear some of this stuff, but it was almost nonstop. This film is 18 years old and in this respect, it shows. I don't believe any movie, R rating or no, would get away with this today.
    • Predictable plot twists. The climax of the film involves the plane landing in Las Vegas. They've cleared the runways for the plane to land at the airport, but of course it's out of fuel. The pilot then announces that he's going to land on - wait for it - the Las Vegas Strip. Cue the crashing neon, screaming crowds, flying propellers... on what seems like an endless loop for at least three minutes. 
    • An unbelievably corny script. Nicholas Cage's cellmate was apparently also assigned to this flight. When Malkovich announces that there's a traitor on the plane and threatens to kill one of the guards, the cellmate does an "I am Spartacus," takes the blame before Cage can confess and gets shot for his trouble. The cellmate, lying on the floor of the plane and looking like he's about to check out, announces that he doesn't believe in God, whereupon Cage responds "I'm going to show you that there IS a God!" as he jumps up and heads forward to take over the plane. (Did I mention that he has shoulder-length Jesus hair?)
    • The ending. Ugh. Our hero has been toting a stuffed bunny rabbit as a gift for his daughter throughout the movie. The blasted thing somehow survives the crash, landing in the gutter in a puddle of mud. Cage picks it up and presents it to his daughter, who promptly hides behind her mother. (I think this is supposed to play on the audience's heartstrings; I admired the daughter's good taste.) Prompted by her mother, who is dressed in a two-piece sweater set and has her hair in a headband and generally looks like she stepped out of Good Housekeeping magazine circa 1962, she takes the rabbit and hugs her daddy. The only thing that cuts the glucose here is the final scene in which we see good old serial killer Steve Buscemi, who survived the crash, shooting craps in a casino and announcing that he feels "lucky."
    I laughed my way through this thing and managed 40 minutes on the elliptical while watching it, so I suppose it did its job. But afterwards I realized something that depressed me for the rest of the day: since 1997, movies have gotten even worse. At least Con Air had an original script. It was not a remake, had nothing to do with Marvel Comics or transformer robots, and had very little CGI. It had a cast of experienced professional actors who did the best they could with the material they had. There were no fart jokes, at least not in the part of the film I saw.

    These thoughts left me asking myself "Whither Hollywood?" I could only answer with a shrug and "Nowhither, I guess."

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    Monday, February 23, 2015
    A View to a Crash

    Driving home from work tonight I turned on the radio and found myself in the middle of a freeway car chase. If you aren't from Los Angeles, you may not realize how frequent a happening this is: L.A. has 527 miles of freeway and a whole lot of cars, not to mention any number of lawbreakers whose first instinct, when the police turn on their flashing lights, is to put the pedal to the metal. The first really heavily televised car chase was back in 1994 and I blame O.J. Simpson and his white Bronco for this whole phenomenon. Tonight's chase was out in the Lancaster-Palmdale area north of the city and was eagerly being narrated by the clowns John and Ken on KFI, a talk radio station with a conservative bent.

    "They say he's going a hundred and twenty miles an hour!"
    "He's slowing down. Why is he hitting the brakes?"
    "He just went into a GATED COMMUNITY!" (The driver apparently rammed the gate, drove in, a passenger [who has since been arrested] jumped out of the car, and then the driver headed back out and onto another freeway. As one of the radio hosts pointed out, this has never happened before in the televised history of Los Angeles car chases.)

    One well-meaning network journalist on television recommended that people in the area keep their children indoors. John and Ken greeted this rather obvious piece of advice with glee and every five minutes would again remind their listeners to lock their doors and stay inside. As I listened I heard that the chase had started in Northridge, in the San Fernando Valley - a good 40 miles back - and that the driver had hit a pedestrian there. No word on how the pedestrian was doing. Who cares? There's a car chase to narrate!

     Eventually the chase petered out, as these things do. The fox - I mean, driver - was run to earth on a dirt road out in Palmdale. Driver then proceeded to sit in his car for about fifteen minutes, before eventually being persuaded to come out of the car, where he was promptly cuffed and will no doubt face any number of charges. I just hope manslaughter isn't one of them.

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    Wednesday, December 24, 2014
    To all who are reading this now, or in the future. The annual Christmas miracle kicked in about 24 hours ago. Traffic has slowed down, nay, has all but disappeared. Peace reigns over Los Angeles (more or less). Merry Christmas to you and yours. Be well and avoid the flu.


    Thursday, October 02, 2014
    Hi There, Captain Trips

    Let's start things off with a picture, shall we? Notice the complete lack of any bioprotective gear on the guy cleaning up the Ebola-laden vomit ejected by Patient Zero on his way to the hospital?

    Sigh. OK, I used to think the US had one of the best public health programs in the world. All that stuff about immunizations, handwashing, treating TB, clean water supplies - you know the drill. But after seeing the way the Ebola case has been mishandled I am beginning to wonder. Read the following (lifted from the Ace of Spades site, and MAJOR props to blogger tmi3rd for his info on the case):
    The patient's quarantined girlfriend Louise told CNN on Thursday that she had not been told what to do with the soiled linens used by Mr Duncan when he was ill and had not been given food. The woman has been legally ordered to stay inside her Dallas apartment with her 13-year-old child and two nephews, who are both in their twenties, as they came in direct contact with Mr Duncan. ... The quarantined family members of Ebola sufferer Thomas Eric Duncan had tried to escape their Dallas apartment after being told they had to stay inside because they were at risk, having been around Mr Duncan while he was contagious... It also appears that Mr Duncan did not mention his close contact with a severe case of Ebola to his partner Louise, with whom he has one child.
    So, yeah. That apartment is LOADED with infected bodily fluids and the local health department (and/or CDC) is telling them to stay in there. I don't see that working out real well. The family is understandably terrified and has already left the apartment once. Why doesn't the city move them to a clean, isolated area?

    Go read Ace, who's all over this story. You won't get better info anywhere.

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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.


    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.


    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.


    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)

    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

    > 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.


    > I don't understand that.


    > 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.


    > You are number 1,752.

    > WHAT.

    > You are number --


    > I don't understand that.


    > 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.


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

    > OH NO


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


    > 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.


    > 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?


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


    > 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.


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


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


    > 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.


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


    > You must be more specific.


    > 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?


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


    > 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.


    > 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.


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