“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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I Used To Do That With Hawaiian Punch and a Straw


Today a patient told me how he kept himself entertained in the hospital during his admission for a GI bleed: he kept clenching and unclenching his stomach muscles to vary the level of blood in his NG tube. To each his own, I guess.

In other news, almost over my jet lag. Thank goodness.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Kona the Wonder Dog


OK, just to cheer you up from the previous post here are some pics of the recent snowfall in Colorado, courtesy of my sister. Included are pictures of their lab puppy Kona - I met him over Christmas and he is adorable.









Brrr! I'll stick to Los Angeles, thank you.

Labels: Doggies, Snow, Travel

posted by Dr. Alice at #

 
Mediball


My flight home from Australia included Moneyball as one of the featured movies. In this film Brad Pitt plays Billy Beane, the general manager of the Oakland A's baseball team. He is faced with the challenge of putting together a winning team on a very tight budget. Fortunately he meets Jonah Hill's character Pete, an Econ nerd recently graduated from Yale, who believes he can find undervalued baseball players by analyzing their stats. For example, if a player does not have a great batting average but often gets on base via walks, that player is more likely to score (although his low batting average causes him to be undervalued). Billy hires Pete to help him find these undervalued players. Although they meet a lot of resistance at first, Pete's theory proves to be correct.

In the course of the film we learn via flashbacks that Beane was drafted out of high school as a promising baseball player. He never lived up to his early promise and eventually quit the sport to become first a baseball scout and then general manager. His experiences give him a very clear-eyed view of professional sports. He does not find baseball romantic; in fact, immediately after the climax of the film in which the A's set a new League record, we see Billy Beane explaining to Pete that he isn't interested in setting records or winning World Series rings. What he wants is to change the game. Left unanswered is the question, is he changing it for the better?

Today at work I sat through a very dispiriting meeting and was irresistibly reminded of Moneyball. The issue is that The Firm has to reduce the cost of patient care. We are at risk of losing several insurance contracts, as we're being told that we as a group are simply too expensive. We, the primary care doctors, have been divided into "pods" and told that we will be meeting monthly to analyze our practice habits; the meeting today was for the pod leaders. (I'd make a "Pod People" joke here, but it is simply too close to the truth to be funny.)

We were handed sheets of paper listing the number of studies and lab tests each of us had ordered in the past year. This included EKG's, echocardiograms, radiologic studies, neurologic studies and so forth. Our "efficiency score" was also included. We were told that the doctors in general are undercoding patient diagnoses. The higher you code, the sicker the patient and the better your efficiency score is (but if you overcode, woe betide you! You will be cast into the seventh circle of Hell - meaning the Feds will sue your sorry ass off.)

Nothing on these sheets of paper said anything about patient satisfaction... or doctor satisfaction, for that matter. Nothing about the pleasure we take in treating three generations of one family, or congratulating a patient on their retirement or a grandchild's marriage, or in saving somebody's life. Nothing, in other words, about the romance of medicine. Our performance was boiled down to a handful of statistics presented to us by a clear-eyed, hardbitten MD in charge of numbers. Now to be fair I know this guy to be a great doctor, one of the Founding Members, who really knows what he's doing. And I also know that he's right and we have to be more efficient in what we do. But today was a new emotional low for me.

I come from a medical family and I often think back to the stories my mother has told me. Her father and his brother ("Uncle Doc") were a dentist and a doctor respectively. They lived in the same small Southern town and shared office space. In that time and place tobacco was the main cash crop. The farmers were flush with cash once a year, after the tobacco auctions, and that was when they paid off their accounts. My mother remembers them coming in: "They'd say 'How much do I owe ya, Doc?' and they'd pull a wad of bills out of their overalls that could choke a horse." My grandfather carried them on account the rest of the year, knowing they were good for it.

Obviously this billing method has its weak points. But as I sit through these meetings belabored with statistics and ICD-10 coding, I often find myself visualizing that 1940's office and wishing I worked there instead of here. At least no one there was reduced to a statistic.

Labels: Medicine, Pop Culture, Random Thoughts

posted by Dr. Alice at #

 

Recognize this?

Australia, ladies and gentlemen.

The Great Barrier Reef, taken from a helicopter (apologies for the poor image).

More pics forthcoming. I wish to thank Tim Blair and his lovely partner Nadia for their generosity and hospitality while I was in Sydney (including letting me ransack their library) and for introducing me to Turkey Flats rosé. If you ever come across this wine, get some. It is great.

Labels: Travel

posted by Dr. Alice at #

 
Catchup Time

(I apologize for brevity here, but I am on the clock at an Internet cafe.)

I only just realized it's been six months since I posted. Unbelievable. I promise more posts will be forthcoming, but not right away. Currently I am in Australia on vacation - a place I have always wanted to go - and am in Melbourne riding trams and drinking coffee. I will post a few pictures as well upon my return.

Yesterday was Australia Day, a sort of combination of the US holidays Memorial Day and Columbus Day. We the newswatching and -reading populace were treated to any amount of guilt from the "indigenous people" of Australia. They actually went after the Prime Minister, who was at a ceremony in Canberra giving awards to emergency relief personnel, and security had to be called to escort her from the mob (who were beating on the glass walls of the restaurant and trying to attack her).

After seeing that spectacle on the news I make no bones about suggesting that the British who "stole" Australia from its indigenous people have accomplished a lot more in 200+ years than the indigenous types who lived here for thousands of years prior to that. And I don't care who hears me say it.

Labels: Random Thoughts, Travel

posted by Dr. Alice at #

 
Chupacabra vs. the Alien


In the past few months I have acquired a Secret Shame so delightful I feel compelled to share. The Shame in question goes by the name of Sci Fi Original Movies. If you ever wondered what happened to made-for-television films (remember the "Movies of the Week" from years ago on major networks?) they are alive and thriving on cable. The Lifetime channel is the proud progenitor of its own set of shameful films, but given the choice between women's exploitation and cheesy science fiction I'll take the movie with the alien in it every time.

A couple of years ago the Sci Fi channel changed its name to the horrendous SyFy but the production company, still known as Sci Fi Pictures, continues to be the savior of underemployed members of the entertainment industry everywhere. These films usually contain one or two reasonably good, recognizable actors to anchor the thing as well as terrible CGI effects and/or guys in monster suits. They are generally filmed in out-of-the-way parts of the world on the cheap; I award bonus points if they are filmed in Bulgaria.

What are the movies about? You can get a pretty good idea by casting your eye down the list of titles linked above. Aliens are quite popular - five movies on the list have the word "alien" in the title; natural disasters such as volcanoes, tornadoes and massive storms; horror flicks featuring monsters or the supernatural. Someone at Sci Fi Pictures really has a knack for coming up with titles: How can you read the words "Reign of the Gargoyles" or "Android Apocalypse" and not be tempted to watch? (Full disclosure: the scriptwriter for "Frankenfish" is a friend of mine. Do him a favor and rent it even if you don't watch it.)

You'd probably appreciate these films more if you're a fan of Mystery Science Theater 3000 and are comfortable with the idea of screaming abuse at your television. Most recently I found myself yelling "That doesn't make any sense!" at poor Xander Berkeley, playing a vulcanologist out to save the world in Magma: Volcanic Disaster. He was expounding his character's theories about what would cause all the volcanoes in the world to erupt at the same time, and none of it was the least bit logical or realistic. Still it was great fun to watch, especially if you are a fan of Mr. Berkeley as I am.

And this is the real reason why I watch these movies. My hobby is crushing on character actors. The chance to see Xander Berkeley in a starring role, playing a good guy for a change? Awesome. I'd watch the guy read the phone book. Want to see Bruce Campbell playing an "astronaut and osteopath" in Alien Apocalypse? Sure you do. John Rhys-Davies as a ship's captain in Chupacabra: Dark Seas, Ron Perlman as an evil corporate head in Absolon - there are many more. It's a delight to watch these actors do their thing, manfully keeping straight faces in the midst of monster makeup and really bad acting from their compatriots.

I wouldn't recommend these films over, say, Citizen Kane but if you're looking for a pleasant way to waste time and laugh your head off I can't think of too many better ways than watching these movies. You can find the SyFy channel's schedule here. Click and soon you too can be watching Bruce Campbell and Stacy Keach in Man with the Screaming Brain.

Which was filmed in Bulgaria. Ten points!

Labels: Pop Culture, Science?

posted by Dr. Alice at #

 
A Pain Chart for the Real World

You know those silly pain charts that are used in hospitals and nursing homes, the one you point to to show your level of pain? Go read this. She's developed a much better one.

Labels: Medicine

posted by Dr. Alice at #

 
Dots on a Map

Lately I seem to spend a lot of my online time on Mapquest. I look up the small towns where my parents grew up, revisit the parts of Philadelphia I remember from college and medical school. I spend a lot of time virtually wandering California's Central Valley, heading north on Route 99 and zooming in on the small farm towns that dot the valley floor. Some of these towns are only a few blocks long. I eyeball the bar scale at the bottom of the map, trying to estimate their dimensions: are they half a mile wide? Less?

Then I wonder what it would be like to live there. Hellish, no doubt: if these towns were thriving they would be bigger, plus the farm economy isn't doing well these days. Not to mention that the Central Valley is hot as hell in the summer. Nevertheless I can't keep myself from daydreaming about retiring there. On the map every one of these tiny little towns is an idyll. Everyone knows one another, it's peaceful there, there's a little high school with a scrappy football team that the whole town supports. Folks sit on porches and drink iced tea.

In real life, the denizens of these towns are probably either dead-eyed clerks at the local convenience store/gas station or toothless geezers who cook up meth in their spare time. I don't want to chance my fantasies being shattered, or ending up like Janet Leigh in the Bates Motel, so for the foreseeable future I'll confine my travels to Mapquest. And when I drive through California it will probably continue to be on boring Interstate 5.

Labels: Random Thoughts, Travel

posted by Dr. Alice at #

 
Head Meets Desk

Annnnnnnnnd today, we have the patient who needs approval for life insurance, whose insurance company faxed a form marked "urgent" in sixteen different places, who hasn't had a physical since MARCH 2008. FAIL.

Give her credit, when I called to explain she was horrified and offered to come in right away, but still.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Don't Read This Post While Eating

Medicine has long been apostrophized as a field in which its practitioners shield themselves behind a layer of fancy words, and rightly so. Sometimes though the words serve a useful purpose: if you have to discuss bodily functions, it helps to use a word that won't gross people out. A case in point is a word I came across in a gastroenterologist's report today: "scybalous." As in, "The patient passed a scybalous stool with mucus."

What the hell does that mean? I wondered. Wormy? Skinny? Scythe-shaped? My imagination ran riot, and I was forced to look it up immediately. Turns out that scybalous is defined as "composed of hard feces" or "pebbly feces." Not an attractive thought to be sure, but using a word like "scybalous" distances the reader from the concept a bit. Gets your head out of the toilet, so to speak.

My search led me to an online medical dictionary, one of those books it's impossible to stop reading. You may find me at that site for the forseeable future.

Labels: Medicine, Random Thoughts

posted by Dr. Alice at #

 
Consider the Following.

Setting up the shot took nearly an entire workday - before they were even ready to begin filming.

Culver City was operating under a water shortage.

He wasn't feeling well, in fact was running a temp of 101° F. The director told him to go home, but he refused and wanted to try one take.

They hadn't choreographed the dance except for the "start" and "end" marks, essentially, he IMPROVISED THE WHOLE THING.

That first take was the take they used for the film.

So now, ladies and gentlemen, I present to you: Singin' In the Rain.

http://www.youtube.com/watch?v=p7QL46cK7B8&feature=related

Labels: Pop Culture

posted by Dr. Alice at #

 
Medicine and the Media, Part Deux


Strap in, people: It's time for another round of controversy. The latest article making the rounds of the medical Twitter world is this piece published in the New York Times - "Don't Quit This Day Job." The author, a female anesthesiologist, makes the case in this essay that women doctors should not be encouraged to work part-time or to leave medicine for family reasons. Since primary care specialties such as pediatrics, internal medicine, and OB-GYN are now largely female, primary care is suffering because of female doctors' choices to either quit or work part time. For her efforts she's been pegged "misogynist" by at least a couple female doctors I follow.

I agree with her. I am not a fan of part-time medicine, and I am one of those annoying old-school docs who feel that a career in medicine is every bit as much of a commitment as a marriage. Full disclosure here: I'm not married myself, never have been. I don't have children and likely never will. I can stay in the office till midnight if I want and I won't disrupt anyone's dinner or miss any Little League games. My father, now retired, was an old school doc who spent a lot of nights and weekends at the hospital - though he made a big effort to come home and eat dinner with us kids, put us to bed, then went back to the hospital to finish rounds. I learned from him that medicine requires total commitment. I never expected anything else. Therefore, feel free to read the rest of this post with a grain of salt.

The part-time medical gig? In my opinion it can't be done, at least not well. Even when you aren't in the office, patients are still calling. Prescriptions need to be filled. Questions have to be answered, labs have to be reviewed. Who's doing this if you aren't? One of your resentful partners who doesn't know the patient, that's who. Face the facts: no one wants to clean up after you. The patients, also, don't appreciate being told that "Doctor So-and-So is out today, she'll call you tomorrow." Trust me, for most patients tomorrow is Not Good Enough. And for a really sick patient, delay can make the difference between being hospitalized and being able to be treated as an outpatient. I think of medicine as a jealous mistress: Anything you do that takes time away from her, she resents. And she will make you pay. But she does reward loyalty.

When I went into practice I joined a group that (in large part) shares my attitude toward medicine. The Firm does employ part-time docs, but we expect people to show some level of commitment to medicine and to your fellow members of the group. If you show up for a job interview and your first questions are about the availability of part time work and how much vacation time you get, you aren't going to endear yourself to the folks who do the hiring around here. We've seen our share of doctors who join the group, get pregnant, give birth and leave the group a year or two later because they find the hours too much (even when working part time). If you're planning a career in medicine you need to know this basic rule: take the number of hours you work per week seeing patients. Multiply it by 1.5 to 1.8. That's the amount of time you're going to spend practicing medicine. The extra 0.5-0.8 goes for phone calls, charting, wrestling with insurance companies for authorizations, etc. It cannot be ignored; you have to factor it in somehow. What I'm trying to say is, There is no such thing as a nine-to-three job in primary care. To quote the author of the NYT piece, "If you want to be a doctor, be a doctor." Don't do this dip-your-toe-in-the-water crap. Be a help to your patients and partners, not a hindrance.

I think often of one doctor who used to be a member of our group. She was a great doctor and a joy to work with, but she left for a hospitalist gig where she could work one 24-hour shift and one 12-hour shift per week and spend the rest of her time with her kids. I can understand her choice, but the group lost a good doctor (after paying for her childbirth leave of absence, I might add) and the patients lost continuity of care. Again. I can't tell you how many times I have been asked by a patient who's been through three or four doctors in our group, "Are you going anywhere?"

I probably should clarify my attitude toward part-time docs here: I respect women who somehow manage to juggle child rearing and work. Frankly, I can't imagine how they do it. No matter what you're doing, you're plagued by guilt that you aren't doing something else: Either your family or your patients are getting shortchanged. Professional women also tend to put off childbearing, so often they are coping with fertility treatments on top of everything else. I absolutely could not do that. But when I hear some of the older docs in The Firm complaining about how all the doctors joining the group want to go part-time, I have to confess my empathies are with the old school. If my fellow doctors are out with fertility treatments/pregnancy issues/sick kids, we have to pay extra to hire locum tenens coverage and/or the other docs in the group get stuck with the burden of caring for their patients. But what about feminist solidarity? I hear from the audience. Screw it, I respond cheerfully. Medical solidarity trumps feminist solidarity. Heck, it even trumps relationships. We have plenty of docs in the group whose careers have lasted longer than their marriages.

But is that healthy? Is that right? they persist. Honestly, it's the way medicine is - at least the way primary care is. The doctor-patient relationship is the anchor of primary care, and if medicine changes to become more family-friendly, it will be the first thing to go. Those of you who disagree: have you had ill friends or relatives? Have you noticed any difference in their medical coverage in the last few years? Are you finding that the doctor you knew simply is not available, or has been replaced by a covering physician whom you don't know? Bet you the answers are yes.

Medicine is a club - not an elitist club, but you do have to earn your way in. Once you're in you are expected to do your share of the heavy lifting. It's an obligation, but also an honor. The more doctors come to view medicine as a part-time responsibility, the more patients will suffer for it. And remember, we're all patients sooner or later. So are our parents, our kids, our friends. I think this is what the author of the article was trying to say. Instead of slapping the label of "misogynist" on her, it might help to think this through. Can you really say that she's not right?

Labels: If I Ran the Universe, Medicine

posted by Dr. Alice at #

 
Gonna Stay Where I Am


As is the standard after any vacation, I had a small mountain of mail piled on my desk to greet me when I came back. Sorting through it I found a pamphlet entitled "Non-Clinical Careers for Physicians: Your Action Plan for the Future." Good Lord, I thought. Are there that many cranky docs out there fantasizing about never seeing patients again?

Apparently there are. The inside cover pitches this seminar as follows:

This course is designed for physicians who:

Don't enjoy going to work anymore
Are interested in making more money than what clinical medicine provides
Want to explore their options [the world's biggest cop-out line - Ed.]
Are frustrated and dissatisfied with their current career

And many other reasons listed, but I think you get the idea.

The seminar includes meetings with employers and recruiters, lectures and 'breakout sessions' on topics like "The Physician Inventor" (OK, that one intrigues me), "Communicate and Network Your Way to a New Career," "Opportunities for Physicians in the Biopharmaceutical Industry" [and in other fields: disability insurance, consulting firms, medical device companies and so forth]. All of this in two days for only $1295 US!

At this point my inner red flag started waving. This sounds like a ripoff. Not in the sense that it's illegal at all, just that any doc who knows how to network could probably figure out a lot of this stuff by asking around. Specialists, drug reps, insurance company staff, talking to their medical school's alumni association... you know, what people who aren't doctors do when they look for jobs.

More to the point, none of these career options sound interesting to me. I do not want an administrative job. I like primary care and interacting with patients, and through good fortune I belong to a stable medical group which pays me a salary. My checks don't bounce; I don't have to worry about paying the office rent. I know not all doctors can say the same. But if I were in that position and money was tight I might moonlight somewhere or (as above) would try a spot of networking on my own first.

The back of the pamphlet offered a fiction writing seminar for physicians later in the year. Now that I may find harder to resist! I've got this idea. There's this primary care doctor, see, who uncovers a bioterrorism plot in between filling out disability forms and fighting drug plans for authorizing medications. It's guaranteed to be a bestseller... if I can just sit down and write it...

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
So Delicious. Must Share.


Last week I returned from a two-week vacation in Italy. Half of said vacation involved a cooking class, which was great fun. It was taught by Arthur Schwartz, a food writer from New York who loves Italy and Italian food. Arthur doesn't do fancy or complex recipes and neither do I, which is a big reason why I was attracted to the class. We made a few different kinds of frittata over the week, but my favorite was this spaghetti and broccoli rabe frittata. We made it with regular broccoli, as the broccoli rabe wasn't available; but tonight I made it with the rabe and OMG, people. You have to try this.

We were blessed with some great kitchen staff who helped out during the class (they washed a lot of dishes and did some of the prep work). One of the women helping out could flip a frittata like nobody's business. She took a big, flat metal pan lid, slid the frittata out of the pan onto the lid, then flipped the whole thing back into the pan to cook the other side. All of us amateur cooks in the class instantly worshiped her. And tonight, by golly, I successfully flipped the frittata myself. Someone should give me the Nobel prize for cooking, I am telling you. (The secret is to cook it until it is really set, which means you have to be patient.)


So, here is my recipe, adapted from Arthur's.

1 bunch broccoli rabe
3 T. olive oil, divided
1 large clove of garlic
salt, black pepper (or you could use hot red pepper flakes)
5 eggs - I used six
1/4 cup of grated Parmesan
about 6 oz of spaghetti, cooked
recipe calls also for 6 oz mozzarella, which I skipped.


There is some prep work involved here, but not that much, and it is oh so worth it. First, clean the broccoli rabe and peel the thick stems. Bring a large pot of water to a boil, salt it and throw in the veg. Boil for five minutes and drain. Then, add the chopped garlic to 2 T. of the oil in a 10-inch skilet, preferably nonstick. When garlic is sizzling add the chopped, drained broccoli rabe and stir it around for a few minutes until tender. Add some salt and pepper.

While you are doing all this, boil the spaghetti till done - I broke it in half first, which worked well.

Beat five eggs in a large bowl very well, add the cheese, cooked and drained pasta and the broccoli rabe. Add another tablespoon of oil to the frying pan and then put in the mixture. You can poke it with a fork now and again to make sure any loose egg on the top filters down. If it looks like there is not enough egg to bind the mixture, beat and add another one. (The egg is not supposed to be the main ingredient, but more of a binder; it is supposed to be heavy on the pasta and veg.)Cook over low to medium heat.

Give this a good seven to ten minutes, then loosen the frittata, slide it onto a plate or a pan lid, then pray to your deity of choice, carefully flip the frittata back into the pan and cook the other side. Try not to eat the whole thing by yourself. Leftover frittata makes a great lunch or snack.

Labels: Ingestion

posted by Dr. Alice at #