“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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Interesting Links

A Microsoft intern has dinner with Bill Gates. At his house.

Austria has issued a stamp of native son Arnold Schwarzenegger.

And a really interesting interview with Dave Barry at the Dems' convention. Turns out he's quite a cynic about the political process.

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Back

Sorry about the lack of posts. My home computer is acting up and I'm going to have to take it in to be brainwashed or put to sleep or something. Also, I was hit with a blizzard of work upon my return. In fact, the pattern of the rest of my summer is clear: work work work. That's okay, though, because summer is generally simpler: the school board isn't meeting, work committees are on hiatus. It's practically a vacation (she said, gritting her teeth).

I realized yesterday - payday - that I'm going to be hit with one hell of a tax bill next year due to all this moonlighting that I'm doing, but I'll worry about that later. The house project is almost done (we haven't mentioned the house for a while, have we?) We're down to the carpet and paint part. Hallelujah. Of late, V. has taken to calling it "The Batcave" (as in, "I can't wait to see the Batcave when it's done.")

One thought about Kerry's speech, which I was listening to in the car last night. His mantra was "Help is on the way!" After hearing this about five times, I started thinking: So, the American electorate is Timmy, and Kerry is... Lassie? Oookaaay...

More later...

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Vacation, Day Two

So today I'm doing my favorite thing: sitting around the house. Only in this case it's somebody else's house - my brother's. I'm having a lovely time playing FreeCell and watching the fog roll in (it's been so hot in LA lately and this is such a relief!)

My bro has a flat in an old brownstone in the area of San Francisco near UCSF. I can't think of many other cities in the States where people use the word "flat", but they do here. It isn't an apartment in the New York City sense of the term, where there are multiple housing units on each floor of a building: Here you get the entire floor straight through to the back. These flats are quite spacious - I think his square footage is bigger than my house.  My brother bought the place about seven years ago; it had been owned by a family for decades, and the holdout surviving relative was a hermit and had (illegally) split the top floor in half and had rented it out to two different tenants. I visited the house back then and it wasn't in good shape - John put a lot of work into it, and it's in much, much better condition now than it used to be. Drawback: the house is across the street from the local branch of the Fire Department, and it is not unusual for the sirens to gear up and the trucks to roll out about 2:00 am. I asked my sister-in-law this morning if that bothered her and she said, "No, I grew up in New York, but it still bugs John."

Last night after I got in I had dinner with my sister-in-law (takeout Greek salads - she got home late) and we chatted about work and, you know, stuff. She works for Yahoo! (exclamation point obligatory) and I asked greedily about the company cafeteria - were the rumors true? "Yep, it's subsidized and seared tuna and couscous are, like, $3.95." Damn. Needless to say, my Firm does not provide such fringe benefits. (The hospital across the street has free cafeteria food for the MD's but they don't run to gourmet eats there.)

This morning I drove down the peninsula to Menlo Park to visit a high-school friend of mine and admire her youngest child (ten weeks old, and a real cutie), then returned and considered driving across town to a coffee house where I used to hang out back when I lived in SF - but then I realized, hey, I can sit here, drink coffee, read magazines and surf the Net for free! And that's exactly what I did. San Francisco is second only to New York in wringing every last drop of tax income from its tourist population; my motto was "I'm not giving those SOB's an effing cent."

Well, that's not quite true. I did go down the street to get a coffee and some Diet Cokes for tomorrow's drive. And then The Bro called and said he had to work late and why didn't I take the N subway out to the restaurant district for dinner? I almost did but then I remembered this place which makes my all-time favorite pizza and ordered from them instead.

The pizza: the Verdi's Special. Pesto (no tomato sauce), spinach, onion and feta cheese with mozzarella atop. No. Better. Pizza.

On to Mendocino tomorrow.

Oh, I forgot to mention one eye-catching ride: the PimpMobile. It's a hot-pink-and-purple stretch limo parked down the block (it makes me wish I had a digital camera!) I'll see if my brother can tell me anything about the car or the owner.




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One Tomato, Two Tomato

Ever driven from Los Angeles to San Francisco? I did today. I took a few days' vacation and came up here to visit relatives. The most direct route, Interstate 5, runs up the center of the San Joaquin Valley through flat farmland. It is a long long drive, if you drive like me; those with lead feet can cover the distance in much less time. Under the best of conditions we're talking over five hours. 

If you make this drive alone it is imperative that you find ways to entertain yourself (a.k.a. stay awake). About halfway through the trip I started noticing tomatoes at the side of the road. They were easy to see - little spots of red fluorescence against the asphalt. Obviously they'd fallen off one of the produce trucks.

I decided to count them. First one, then another two fairly close to each other, then a gap, then another two (they seemed to come in pairs)... then we hit a rough patch of road and holy cow, there's a whole pyramid of them...

I was coming up on a tractor trailer full of tomatoes. Ah, I thought, so it's his fault! Sloppy driver. But no, up ahead of him were yet more tomatoes on the side of the road. I had counted  more than eighty (not including the pyramid) by this time. I was beginning to feel sorry for the poor, split, crushed tomatoes left to rot by the side of the road. Suddenly I visualized an organization that would stand up for discarded produce: PETT (People for the Ethical Treatment of Tomatoes). Their slogan? "Why must the lycopenes suffer?"

At that point I realized I needed to take a rest break.

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Dark and Stormy Night
 
The Bulwer-Lytton Fiction Contest results have been released. Here's my personal favorite:
 
Galileo Galilei gazed expectantly through his newly invented telescope and then recoiled in sudden horror -- his prized thoroughbred's severed neck, threateningly discarded in a murky mass of interstellar dust (known to future generations as the Horsehead Nebula), left little doubt about where the Godfather and his Vatican musclemen stood on the recent geocentric/heliocentric debate.

(via Bookslut)

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...And He Lived To Tell About It

Only Ernie would have come up with this one:

I Gave My Cat an Enema

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Paradigm Shift

Just logged on to Amazon and saw the following, so help me:

My Life was released today (sic); we thought you'd be interested because you bought Garage Sales 101.

Huh?! Other than the obvious joke that Clinton's book is likely to end up at a lot of garage sales, I don't see the connection.


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Weight Loss Surgery? I Don't Think So

From American Medical News comes this interesting (and relevant, to us primary care docs) story on weight-loss surgery:

Bariatric Patients Need Lifelong Care (or, as I would put it: "Duh.")

A few years ago no insurance plans would pay for bariatric (a.k.a. weight-loss) surgery, or would do so only reluctantly. In the last two to three years that has changed significantly, as insurance plans have set specific indications for this surgery; in some cases even teens are now being approved (though this is still controversial). Many of the older surgical protocols are no longer being authorized, as long-term studies have not borne out their effectiveness and/or safety. In my practice more and more patients are applying for surgery and are being approved; I'm guessing maybe ten of my patients have had this done in the last year or two.

I still have problems with this approach to weight loss, though for the right patient it is undoubtedly effective. Here's my biggest issue: surgical treatment does not deal with the primary drive to overeat, which is emotional (most of the time, anyway). Patients are supposed to receive psychological screening prior to the surgery, but in my experience this is a joke. My medical director once asked, rhetorically: "Has anybody ever had a bariatric patient turned down by the psych team?" (Nobody had.) I have seen patients regain huge amounts of weight, once they figure out how to "outwit" their surgically revamped digestive tracts. Some patients never lose weight in the first place, at least not much, for the same reason.

How do you outwit a gastric bypass? Well, the commonest way to do so is via "liquid" calories - meaning high-calorie, low-volume foods such as smoothies, ice cream, chocolate and booze. When I tell patients that they'll have to make a conscious effort to avoid such foods after surgery, and that they'll still need to exercise in order to achieve maximum weight loss, their faces fall. I really think people are viewing bariatric surgery as some sort of "magic" effort-free method of losing weight. Speaking as someone who has struggled with a lifelong weight problem, I can empathize with this, but I feel patients need to be warned both about its true effectiveness and about the lifetime consequences of such surgery.

The article emphasizes the importance of continuing dietary supplements postoperatively - this is a lifelong requirement. Unfortunately, many patients are not doing this. The supplements are often not covered by insurance (they're "vitamins," not medications) and can be expensive. For instance, many postsurgical patients will suffer from iron-deficiency anemia unless they take an iron supplement specifically formulated for people who have difficulty absorbing iron. They're also at higher risk for B12 deficiency and osteoporosis, as well as deficiencies of fat-soluble vitamins. Some patients need to be followed with blood tests to check for deficiencies as well. Every managed care doc cringes at the thought of being confronted by a patient clutching a list of esoteric, expensive lab tests ordered by a surgeon who doesn't give a damn how much they cost, because he didn't sign a capitation contract with a lab.

Lastly, as the title of the article suggests, we primary care MDs need to be educated about the type of care such patients need. Do they need to be screened for osteoporosis sooner? How often do they need labs? Will they need to be colonoscoped more frequently? Do different surgical techniques carry different long-term risks? I don't know the answers to these questions. If anyone can recommend a good source of information (Internet or otherwise) I would love to know about it. In the meantime, read the article if you haven't already - I think you'll find it educational.

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He's Not Paranoid, They Are Out to Get Him

Just found an interesting new Industry blog (what do you mean, 'which industry'?) via L.A. Observed called A Fly on the Wall. Said blogger is anonymous, at least for now.

Lead article today: Michael Eisner's office has been bugged. The listening devices were apparently found during a sweep of his office over the long holiday weekend. The post goes on to state that

Eisner routinely pays for a security sweep by electronics experts every few months out of his own pocket. This is the first time evesdropping bugs are believed to have been found.

After some apparent internal disagreement, Disney officials decided not to alert the Burbank Police Department about the security breach. Disney is notoriously closed-mouthed with Burbank city officials about studio operations, and Burbank police are not allowed on the walled and gated studio lot unescorted.

As to who may have planted the bugs, the list of Eisner's enemies is slightly longer than the Manhattan telephone directory. Some of his current high-profile battles include an ongoing showdown with Miramax's Harvey Weinstein and also a bitter feud with a Roy Disney faction for control of the company.

I don't know where the guy gets his info, but if accurate, it sure is interesting. If you scroll down you'll find another interesting article about celebrities registered to vote in more than one location. "Vote early, vote often"? Hmmm...


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"You Got Your SciFi in My Mystery!"

Scifi mysteries are the Reese's Peanut Butter Cups of literature. (One of the pleasures of having a blog is being able to write sentences like that.) By saying that, I mean that each is such a recognized genre in itself that to combine the two seems a little shocking at first - too much of a good thing? Or, for those who like one genre but not the other, why spoil my good thing with this other stuff? (I admit I've never been that much of a scifi fan.) Nevertheless, I recently have had the good fortune to come across three books that I can recommend for summer reading which fall into this category.

The first two books, Bimbos of the Death Sun and Zombies of the Gene Pool, are by Sharyn McCrumb. She has written many other mysteries which don't involve scifi, but these two deal with the adventures of college professor Dr. James Owen Mega, aka novelist Jay Omega. Dr. Mega wrote a solid scifi novel and had the misfortune to sign with a publisher who slapped the lurid title "Bimbos of the Death Sun" on it, hoping it would increase sales. Half the fun of these books comes from watching Mega cringe every time the title of the book comes up. Interestingly, McCrumb likes to focus on the culture of scifi fandom - in the first book there's a murder at a fan convention; in the second, one of a group of scifi writers is murdered at an authors' reunion. Apparently "Bimbos" has acquired a cultlike status among scifi fans and has been used by actors attending conventions as a sort of orientation tool! It's straight-out funny, "Zombies" somewhat less so, but both are worth reading.

My third recommendation is definitely scifi, albeit filtered through Raymond Chandler's noir sensibility: Gun, With Occasional Music. It's also a lot darker than the first two, happy ending definitely not included. At the beginning of the book, author Jonathan Lethem quotes Chandler stating that a suspect was "as easy to spot as a kangaroo in a dinner jacket": it's clear that this line gave him the idea for the book. It's set in Oakland sometime after 2008. The printed word has been outlawed. Everyone's hooked on a drug called "make" (you snort it), including the detective narrator. The population is now made up not only of humans but genetically modified animals with human intelligence and the capacity for speech. We meet a sheep, a kitten, an ape, and yes, a kangaroo. The scenes involving the detective interacting with the cops (now called Inquisitors) are straight out of Chandler. Strange, nightmarish, and very good.

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BINGO!

Last week I saw a patient who was complaining of general pain on the left side of her body, but more particularly of pain in the hands and wrists. No pain in the feet. She felt generally unwell. On a hunch, I checked titers for parvovirus - and hit the jackpot! Her IgM (acute antibody titer) was through the roof.

I see a case like this about every one to two years. It's satisfactory because you can put a name to the problem and reassure the patient that the symptoms will go away and they're going to be fine.

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Third of July

Today is the anniversary of one of the most memorable days of my life. It's a day I love to remember. Not that it was important in the conventional sense - no graduation, no proposal or anything like that, but it was one of those days that stands out in the memory years later. I can't remember what year it was - I was about seven - but I know it was the third of July, because it was the day before Independence Day.

One of my father's patients was a strawberry farmer in Orange County (these were the days when Orange County still had large tracts of farmland scattered through its urban areas). It was the end of strawberry season, and he invited Dad to bring his family and pick all the berries we wanted; he was going to plow the field under in the next couple days and plant his next crop.

So that's what we did. We went and picked berries. The nearest I'd gotten to picking fruit before was the lime tree in the backyard, not known for its productivity. I remember a sunny, breezy day, bending over to see the bright red berries on the ground and smelling the moist earthiness coming up from the plants. It was marvelous. We picked and picked, then came home with two huge flats full of dead-ripe berries. After we'd all had a bowl apiece, there were still tons left and it was obvious that we'd never be able to finish them before they rotted - they were just too ripe. My mother thought for a minute, then resignedly picked up the phone, called her mother in Tennessee, and asked:

"How do you make strawberry jam?"

Mom made jam! Better yet - strawberry jam! And it was summer vacation - and the next day was the Fourth of July, with the promise of fireworks. Could life get any better for a seven-year-old kid?

This third of July is different. I'm on call, and just got back from making the rounds of the nursing homes. Earlier this morning, I admitted a patient of mine with severe pneumonia, only to watch him die in the ER. (He was horribly ill, and his friend who had power of attorney agreed to extubate him; it was the right decision.) But every year I think back to the kid who picked berries with Dad and watched Mom make jam, and now I realize that the seed for this year's third of July was planted all those years ago when I watched my father's patient thank him for his care the only way he could: by putting his crop at our disposal.

His name was Tamaguchi. Thank you, Mr. Tamaguchi, for my third of July.

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Weekend Roundup

Various unrelated but interesting links for your long weekend:

Via Bookslut, a link to an interview with Alain de Bottoin. Do read it, and I can highly recommend How Proust Can Change Your Life. I haven't read any of his other books, but I intend to.

The Fourth of July is Dave Barry's birthday. Stop by and wish him the best.

L.A. Observed has an excellent post on local writer D.J. Waldie, who first became known in 1996 for his book Holy Land: A Suburban Memoir. Part autobiography, part urban study, it became an instant classic. He's published a new collection of essays that has been well received. I'd recommend anything this man has written, especially if you live in Southern California - but he's worth reading even if you don't. His story is an interesting one. He lives still in the small house in Lakewood where he was born and raised in the Fifties, has never married, and works as a civil servant for the city of Lakewood. I get the impression he lives to write, and specifically to write about L.A. He does a wonderful job.

Via Tim Blair, it's "Rock, Paper, Saddam!" Give the pictures time to load. Muhaha.

And finally, via Ernie, it's the Amazon.com Knee-Jerk Contrarian Game! Here's how it works. Go to Amazon, pick a favorite book or movie, and rank the reviews in reverse order (worst first). It's quite entertaining. Here are a few samples:

On the film Seven Samurai:

Save your money and time by not watching this badly made kung-fu movie. The guys in this movie do not know martial arts at all.

This movie seems to be a scene-by-scene copy of one of my favorite movies-"Magnificent Seven". Magnificent seven is a classic movie that has been copied many times, but I didn't know westerns were popular enough in japan to be copied.

Uh, well, okay, how about Citizen Kane?

"The only good thing about Citizen Kane is that it will put you to sleep faster than any film."

"Please stop the hype on Citizen Kane. It doesn't work. It's like you are trying to convince people that poop smells good."

"Citizen Kane is a hymn to all filmmakers who have ever tried to create something artistic and meaningful and failed miserably every step of the way."

"It was just a bad attempt at a boring story about newspaper tycoon. It's one of the worst movies I have ever seen."


And there's so much more. Enjoy.

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Question of the Day

From an anxious patient contemplating pregnancy, this message:

"I eat a lot of sushi. Do you think I should be tested for mercury?"

No. No, I don't. But I do think you should lay off the sushi.

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