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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    Wednesday, June 30, 2004
    Capitalism 101

    Your assignments: Lileks on The Parable of the Steps. The Food Whore on The Parable of Why Catering Costs More Than Doing It Yourself. (You may have to scroll down; it's the "Good Whores Don't Come Cheap" post.)

    You'd think people would have figured it out by now...

    Monday, June 28, 2004
    Worrisome News

    Via The Lost Blogs Home:

    Thousands of Blogs Fall Silent

    Blogging pioneer Dave Winer unexpectedly closed Weblogs.com, his free blog-hosting service, on Sunday, leaving thousands of bloggers without access to their blogs. Blogs affected by the shutdown now redirect to a generic message posted by Winer. Some bloggers are screaming that the shutdown is a serial "blog murder."

    I wouldn't go that far, but I can certainly see why people would be upset. Winer is going to try to allow users to save and archive their blogs on their computers by emailing them their files. The controversy here is that paying bloggers are now saying, "Idiots, what did you expect?" or similar.

    Is this incident going to separate 'pro' paying bloggers from 'amateur' free bloggers? Is this the beginning of the end for free blogging? Stay tuned to find out!

    Oh, and now I'm going to try to figure out how to save my posts, just in case...

    Phone Call of the Day

    I got a message that "Patient called with allergy question."

    OK. Here is what she said: "I have an allergy to cats but I'm about to get one. What can I take?"

    Lady, don't get the freaking cat!

    Oh, wait. No, that was my fantasy reply. What I actually recommended was for her to try over-the-counter Claritin and keep the cat out of the bedroom.

    Nothing against cats, but if you're allergic no medication works as well as avoiding the allergen in the first place.

    Warning: Cute Baby Story Ahead

    My mother told me this story today and I just had to pass it along:

    My youngest nephew just turned two. His name is William, but lately he's become known as Trouble, as in "Here comes Trouble."

    Last weekend my sister and her family went to her in-laws' for dinner. Dessert for the kids was ice cream bars. The freezer in which the ice cream bars are kept is in the garage, which has a connecting door to the kitchen.

    So dinner was over and the adults were trying to have a conversation, when the doorbell rang. Outside was William, with an ice cream bar in his hand. He'd opened the door, gone into the garage, gotten into the freezer, extracted a bar and gone around to the front door and rung the doorbell to be let in! After discussion, my sister made William share the ice cream bar with his brother, and barricaded the door from the kitchen to the garage.

    It gets better: shortly after this, it started raining. My sister's mother-in-law decided to open the front door but leave the screen door closed to watch the rain. They continued with their conversation and soon there came a tapping at the screen door. It was William again, with bar number three in his hand. He'd sneaked out the screen door and gone back to the garage.

    At that point my brother-in-law gave up and shouted, "That's it, everybody into the car! We're going home!" (And William was made to put back the ice cream bar.)

    See what I mean about "Trouble"?

    Thursday, June 24, 2004
    Thursday Afternoon

    Set the scene:

    It's my half day. Our Medical Director is out on vacation, as are many other members of The Firm. I, Dr. Alice, your host, have been nominated Acting Medical Director because all of the Usual Suspects who would normally cover this job are also on vacation. This means, among other things, that I have been put in charge of STAT insurance referrals.

    I have no idea what the hell I'm doing.

    Here we go:

    Dr. Alice picks up a chart and reads the message. Message says, [Patient] states her insurance has changed so she needs another prescription called in for her [anti-depressant.]

    Dr. Alice:
    I hate you.

    Dr. Alice picks up phone and calls refill to pharmacy because her medical assistant has left early (after all, it's Dr. Alice's half day!)

    Secretary appears with armful of faxes.

    Dr. Alice:
    What are those?

    Secretary, nervously: These are from UR [Utilization Review]. She called a few minutes ago and said you had to review these.

    Dr. Alice flips through pile of faxes, most of which consist of requests for breast reductions and extensions of physical therapy with reams of documentation attached.

    Dr. Alice:
    Oh shit.

    Details of chart reviews and decisions omitted, due to risk of stupefying boredom. Assume decisions are made.

    Page on telephone intercom:
    Doctor, it's Generic Geriatric Nursing Facility. One of Dr. X's patients was just admitted. [Dr. X is on vacation and she's in my call group.] Who's going to follow the patient until she gets back?

    Dr. Alice quickly consults call schedule, which is hanging on the wall: Dr. Y is on call today, so he gets the patient. (Standing rule. It's the law of the jungle.)

    Voice on Intercom: Well, uh, should I tell them to call him?

    Dr. Alice: No, it's better if I do it. I'll leave a message on his voicemail and then run like hell.

    [Tinny giggle from intercom] They need admission orders verified. Will Dr. Y do it?

    Dr. Alice, in resigned voice: No, I will. (No need to add insult to the injury I'm inflicting on Dr. Y.)

    Orders verified. Message left (very apologetically) for Dr. Y.

    Dr. Alice returns to her previous activity of leaving messages for patients; calls random patient, gets answering machine message consisting of 45 seconds of rap music.

    Dr. Alice:
    I hate you.

    And so the long day wore on.

    Human Interest

    Couple things for you. First, this link to a nice story from the Wall Street Journal about items found in used books. (Thanks to Bookslut for the link.) Second, a recipe. (Time I gave back to the food blog crowd after all my taking from them.)

    This recipe is actually from the Sweet Potato Queens' cookbook, which could also be called Eat What You Want and Die Like a Woman (see cookbook post below). It's called "Hal and Mal's Come Back Sauce." It can be used as salad dressing or as a dip for veggies or shrimp.

    Put the following in a food processor or a large blender:

    3 cloves garlic
    2 C. mayonnaise
    1/2 c. ketchup
    1 C. salad oil
    2 tablespoons cracked black pepper (no, this is not a typo)
    Juice of 2 lemons
    2 tsp. mustard
    2 tsp. Worcestershire
    2 dashes Tabasco
    1/2 onion, chopped

    Whiz till it's blended.

    I tasted this and thought, baby, where have you been all my life? It's a bit like Thousand Island or Russian dressing, but with a bit more kick to it thanks to the lemon juice, mustard, Tabasco, etc. You can cut back on the pepper but if you're using it as a dip I would recommend using the whole 2 tbsp.

    It's not low fat - obviously - but it is good. The recipe makes a ton.

    Enjoy In Moderation

    Yesterday, I'm not sure why, I wound up doing a web search for TV drinking games. The best two I came up with (closet fangirl that I am) were the following:

    The Quantum Leap Drinking Game

    The Doctor Who Drinking Game

    As always, it's the cliches in the shows that make these so entertaining to read about. (Play at your own risk! hic!)

    Somebody Should Get These Kids to Clean Their Rooms

    I didn't realize Russia has hackers too:

    A teenager who sent an obscene text message to 15,000 cell-phone users has become the first computer whizkid in Russia to be convicted of sending "spam."

    The best part of this story was the awkwardly constructed last sentence:

    Russia has gained notoriety for its large number of talented and often disaffected young computer experts, whose bedrooms are regularly suspected of spawning major viruses.

    Tuesday, June 22, 2004
    Not New, But Funny

    The Onion scores again:

    EDINBURGH, SCOTLAND - Speaking though her publicist, author J.K. Rowling shocked fans and the publishing world Monday when she announced that she has opted to end the best-selling Harry Potter series because she has discovered boys.

    According to Knowles, instead of working on the as-yet-untitled sixth installment in her series, Rowling has spent the past two months sunning herself at the beach, reading fashion magazines, and talking on the phone for hours.

    Mal de HMO

    Gee, it has been a while, hasn't it... sorry. I could tell you all the excruciating details of what I've been doing the last two weeks, but suffice to say, I've been busy. Also creatively burnt out. But I do have topics to write about and will step up posts this week.

    I will share with you a recent bemused email from V. on the subject of How Your Health Insurance Funds Are Being Spent:

    I referred a patient to ENT & Neuro for persistent dizziness after a cruise. Ultimately, she had a VAT (Vestibular Autorotation Test). Tne upshot was that she suffers from Mal de Debarquement, "a syndrome defined by persistent sensation of swaying or rocking, particularly following sea travel."

    Golly, I'm sure glad we spent the money for that eval.

    OK, ok, we documented that she doesn't have anything worse & with this documentation, mayhap the ins. will auth vestib rehab. therapy. I dunno. But, dang!! We had to send her all over creation to make the diagnosis of Mal de Debarquement - when I thought she suffered from some sort of persistent sea sickness. Tres chic!!

    World's Best Cookbook Title

    Eat What You Want and Die Like a Man.

    (As a doctor with some frayed, residual sense of ethics, I cannot recommend this.)

    Wednesday, June 09, 2004
    Twenty-One Gun Salute

    My secretary brought in a tiny black-and-white TV today and I've been watching the funeral procession all afternoon. It is remarkable to see how many people turned out to see Reagan, both in Simi Valley at the library and now in Washington.

    I'm getting eerie echoes of the past here; I was born four days after Kennedy's assassination, and my parents have often told me of the weekend my mother spent in the hospital prior to my birth (she was at bedrest for pre-eclampsia). My father managed to bring in a small TV and get it hooked up. My mother said the nurses were in and out of her room constantly to watch the news (this was well before it was standard procedure to have televisions in hospital rooms). The Kennedy funeral was the blueprint for the Reagan funeral arrangements, so it gives me an idea of what my parents saw that weekend.

    I'd also like to leave you with this quote:

    [Reagan] was put on earth to do two things: kick butt and chew gum, and he ran out of gum around 1962.

    That pretty much sums it up.

    Thursday, June 03, 2004
    Well, That Was Fast

    The gentleman I told you about yesterday died at five o'clock this morning.

    It's probably the best way it could have happened.

    In This Bridal Season...

    I can't do better than to direct you to this weblog. It's written by a caterer who calls herself a Food Whore and it's hysterical. The descriptions of the weddings are priceless, particularly this one ("I Won't Even Get Out of Bed For $5").
    (via Very Good Cooking)

    Wednesday, June 02, 2004
    You Never Know

    So I've got another dying patient. We seem to go through cycles of this kind of thing (what V. calls "the thinning of the herd"). This fellow is in his nineties, has severe heart failure and kidney problems, and peripheral vascular disease (translation: his foot is turning blue due to lack of blood). He has lived at home with a caretaker and close attention from his daughter, but in recent months has become weaker, had multiple visits to the hospital, and has had two episodes of pneumonia in the last year. This time when he went to the nursing home for rehab he was too weak to participate in the therapy sessions, and he's stayed there ever since, more or less bedridden. The ulcer developed two weeks ago. The vascular studies I ordered confirmed that he needed surgery (you know it's not good when the report says "critical ischemia").

    So I reviewed the report and thought: OK. This man would likely not survive surgery. He'd never consent to an amputation, and a vascular bypass on his leg would require an angiogram to see if he had operable disease; the dye used in the angiogram would likely wipe out his kidneys (which are hanging by a thread). After discussing all this with his daughter, she agreed with me and I referred him to hospice care. We're going to focus on pain control and comfort care.

    When cases like this stick in your head, it's usually not the disease process that you're thinking of, it's the patient. So it is here. The case I just described is not unusual for internal medicine - a bundle of disease processes, each playing off against the other, forcing the doctor to choose a treatment strategy. Not that this isn't interesting - it has a lot to do with why I enjoy my job - but I'm remembering something else.

    I picked this patient up about two years ago when his previous doctor left the group. His chart was the size of the phone book, and I was too busy keeping up with his meds and his various illnesses to go much into his past history. About two months ago, with the worsening of his illness, the patient became more depressed and I decided to get a psych consultation to see if medication would help. When I saw the consult note, this is what I read:

    Patient is a Holocaust survivor. His first family (wife and children) died in the camps. After the war, patient remarried. His daughter Ms. X [who is the one who stays in touch with me] is a product of his second marriage.

    Holy crap. I didn't know.

    I keep thinking of this man who fought so hard to survive, whose body is now betraying him and falling apart. He has his daughter, and his caregiver, so I suppose things could be worse; but I can't do much now except ensure him a comfortable death.

    I will do that. I promised his daughter.

    Go Ray Bradbury

    In 1953 Ray Bradbury wrote a sci-fi classic called Fahrenheit 451. Michael Moore "borrowed" this title for his documentary, Fahrenheit 9/11. How does Bradbury feel about this?

    He's not happy.

    (via Tim Blair)

    Tuesday, June 01, 2004
    Old Guard Vs. New Guard

    A couple weeks ago The Firm held one of its quarterly partners' meetings. These meetings are generally long and dull, as I suppose the meetings of most businesses are. They are enlivened in the first half hour by the serving of dinner ("Pollo Loco again?")and by the chance to chat with one's fellow MDs. The Firm is pretty big, and our members are spread among four or five different offices, so in many cases we only get the chance to talk in person at one of these meetings.

    At this particular meeting an issue came up which illustrated - to me, anyway - the changes taking place in medical culture. The topic at hand was partnership. To be more specific, a doctor who has been with us for two years (the traditional length of time before a member qualifies) was under discussion for possible partnership. She works hard, is respected by all the MD's in her office, and is committed to the group. The problem is, she works part-time (though more than 50%) and no one in the history of The Firm has ever been admitted to partnership without working full-time for at least two years. We have several doctors who work part-time, mind you, but all of them worked full-time for years before switching. Thus the debate: could anyone not working full-time even be considered for partnership? Forget prorating benefits, forget her skills or commitment. Would The Firm even be willing to consider a part-timer as a partner?

    Three of the senior docs (all male) immediately voted no. They gave various reasons but they all boiled down to a variant on "Can we rely on anyone who isn't willing to commit fully to the group? Do you realize this means that someone working part-time might then qualify to be a member of the board of directors?" (because any partner can run for the board).

    You could feel the atmosphere change in the room. Every woman sat a little straighter. All the part-time doctors in the group are female, and they all have kids - this is of course their whole rationale behind working part-time. Hands started going up. "How are we supposed to attract women physicians if we aren't willing to take part-time MDs as partners? You know the demand for female physicians these days, and let's face it, most of them are going to have kids. We've got to do this."

    I'll spare you the rest of the debate. Suffice to say that the Old Guard was voted down in a landslide. They looked somewhat taken aback but accepted the situation with good grace. There are lots of details still to be thrashed out, but it looks as if the old mindset of "Forget about your family, Medicine comes first" is changing.

    The following week I was chatting with V. and told her about the events of the partners' meeting (she'd missed it, being on vacation). Specifically, I told her about Dr. X, one of the old-timers who'd led the Old Guard in arguing against granting part-time docs partnership. Her response was succinct:

    "Who raised his kids?"