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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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    Sunday, September 24, 2006
    Curtains for Aldo?

    For those of you following plot developments in Mary Worth, and I know that all of you are--

    No, wait. Let's try this again. For those of you who read The Comics Curmudgeon, the latest plotline in Mary Worth has been an endless source of entertainment. I'm actually sorry to see it coming to an end, though the end looks pretty damn spectacular. Or to put it another way, it's the weirdest strip I've ever seen. I'd pay to know what the artist was smoking when they came up with this one.

    If you still don't know what I'm talking about, here's some background. Mary Worth is a postmenopausal widowed busybody who lives in the fictional town of Santa Royale, California, in a condo development called "Charterstone." Basically the strip is a soap opera, with issue after issue cropping up. New characters are introduced for each plot, Mary sticks her nose into their business, and when the plot is resolved the peripheral characters disappear, never to be heard from again. The current plot has attracted a lot of attention from readers because a) it's halfway interesting and b) it was presented in a very strange way. Basically, there's a stalker at Charterstone pursuing Mary Worth.

    Yes, I said Mary Worth. Our stalker, who bears a strong resemblance to Captain Kangaroo and looks at least twenty years younger than his prey, decided to go after Mary instead of one of the younger women who seem to infest the place as background figures. Why? Who cares? It's Mary Worth-land, where no one makes decisions that bear any resemblance to reality as we know it. Anyway, after making several halfhearted attempts to woo Mary, Aldo was dragged into an "intervention" organized by her concerned neighbors, who told him in no uncertain terms to leave virtuous, meddling Mary alone. Heartbroken, Aldo responded by hitting the liquor store and then going for a drive with his good friend Johnny Walker. In a remarkably poorly drawn sequence, he then missed a turn and sent his car nosediving off a cliff; I assume that means he's dead, but I'm waiting for tomorrow's strip to find out for sure.

    What response has this plotline gotten from readers? Suffice to say, there are a lot of people out there who are incredibly creative and have a LOT of free time on their hands. As follows:

    • My favorite reader comment from Josh's site: "If Aldomania doesn't end with Aldo shrieking maniacally, a bottle of Bombay in one hand and Mary's head in the other, backlit by the flames of the burning pyre that is Charterstone, I for one am going to be disappointed."
    • Two very clever parodies, one a takeoff on Shelley's Ozymandias and the other of Marvell's To His Coy Mistress.
    • A Benny Hill- type video you aren't going to believe. See below.

    Anyway, it's been fun, Aldo. It's safe to say you will be remembered.


    Aldo Stalks Mary Worth


    How to Write Hate Email

    This is simply hilarious. As a bonus, it's well-written too! (The best part is, it's Part 3 in a series... the writer must be a masochist.)


    Saturday, September 23, 2006
    Sun Tea

    This is a minor thing really, but it's improved my quality of life, so I hope you'll forgive my blogging about it. For those of you not from the U.S., iced tea may not be a big issue for you, but if you're from the States -- especially the Southeast States -- it truly is. (My mother is from Tennessee, so I consider myself half Southern.)

    I do love me some iced tea, but until the last two months I hadn't made any in quite some time simply because I didn't have the appropriate vessel to make it in. To start with, I will not drink instant tea. I consider it evil and no true beverage at all. You can brew iced tea by making it double strength (twice the normal number of teabags) and then pouring it hot over ice, but I've never really liked to do that. I just feel like it shocks the tea, though I have no rational reason for feeling this way: I think tea is a somewhat fragile beverage and should not be jerked around in that fashion. I prefer to brew my tea in the sun (a.k.a. "sun tea"). It's simpler, for one thing, and does not heat up the kitchen. I also think it gives better-tasting iced tea.

    All you do is measure out the water, place it in a glass bottle or jar, add the appropriate number of teabags and leave it in the sun for several hours. You can leave it all day if you want, it doesn't seem to matter (I have heard you can also leave the teabags in water overnight for "moon tea," but I have never tried this). Then strain the teabags out and put the tea in the fridge to cool down. It stays good for several days. I don't sweeten my iced tea, and lately I've even stopped putting lemon in it - if you take care with brewing the tea it tastes good enough that you don't have to. It cools you down like nothing else.

    A few months ago I finally found a glass jar the right size for brewing tea; these days, with so many commercial foods packed in plastic jars, this is harder than it sounds. It's a 1 1/2 quart size dill pickle jar. (My first few batches of tea tasted faintly of dill; this may sound offputting, but it was actually pretty good.) On the occasions that I had my act together I would put the teabags (3) in the jar in the morning, fill it up with water, and park it on the patio in my backyard where I knew it would get the full effect of the sun in the afternoon. When I arrived home, voila - iced tea, already made.

    The season is getting late for it, but if you have the right-sized glass jar sitting around the house I would encourage you to dust it off and give sun tea a try if you haven't recently. You'll enjoy it.


    Friday, September 22, 2006
    Best Chief Complaint Ever

    From a patient who presented today with tonsillitis:
    "My tonsils look like dead alien babies!"
    They sure did. One course of antibiotics coming right up.


    Thursday, September 21, 2006
    "The Glamour of Medicine"

    A few days ago I dropped into the hospital cafeteria to grab a quick bite of lunch. I wound up at a table for four with one of my partners, a podiatrist we both know well, and another MD newly on staff. I introduced myself and the talk meandered into personal backgrounds, such as where-did-you-grow-up and how-do-you-like-Los-Angeles. After some gloomy talk about the current state of health care, we started to talk about having doctors for parents (not all of us at the table fell into this category).

    "My dad tried to talk me out of going into medicine," I contributed. This is not unusual among children of MD's. Pretty much everyone in my med school class with a doctor for a parent reported that at one point or another, Daddy - usually it was Daddy - had tried to tell them that medicine is a difficult job and that it no longer pays commensurate with the work involved. (I do not include specialists here, though their opinions may differ on this subject. I am speaking of primary care because that's what I know.)

    At this point one of the older physicians on staff, a neurologist, joined us and we included him in the conversation. He told us his son had decided to go to medical school. "What did you think about his decision?" we asked, wanting some firsthand input.

    "Well, I tried to be honest about it. I told him what I like about being a physician and what I don't like. But he's been doing some volunteer work, and he was attracted by..." he shrugged. "The glamour of medicine."

    Simultaneously, the rest of us burst into laughter. The questions came thick and fast:

    "Has he ever had to sew up a drunk?"

    "Ever done a pelvic exam on somebody with bacterial vaginosis?"

    "Has he spent any time in the ER at all?"

    He chuckled good-naturedly at our cynicism. "It's what he wants. He's decided it's what interests him, and I said, 'Good for you.'"

    This discussion stayed with me the rest of the week. Usually the doctors' dining room isn't good for much except CNN updates and endless pontificating on the state of the world today. If I could vandalize their TV and get away with it, I'd do it in a heartbeat. But hearing what people think about this profession - would you defend what you do to somebody else? Is it worth it to you? - this stuff truly interests me.

    I have a standard quip for patients who ask me if I like being a doctor: "It depends on what day you ask me." The truth is, though, I do. I can't think of anything else I would rather be doing, or even of any other job I'd be suited to do. If a friend or relative were to ask me about becoming a doctor, I wouldn't tell them not to do it. Like my neurologist acquaintance, I would try to give them the most balanced picture that I could about what it's like to be a doctor. It might well involve phoning my hapless apprentice at three in the morning to complain about nonexistent chest pain or a UTI, just to make sure they get the full experience... but I'd be sure to include the satisfaction that comes with helping someone feel better or achieve a better quality of life. I feel lucky to have a job that has more meaning attached to it than just a paycheck, that has - for want of a better word - "glamour."

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    Thursday, September 14, 2006
    Google's Advice of the Day

    How to remove a hickey. Potentially useful; I'd never heard of most of these ideas.

    One of the most embarrassing--although not particularly amusing--moments of my life was the time I had to testify in a criminal case. The charge was spousal abuse, and the plaintiff was my patient who'd been beaten up by her husband. The defense claimed that the patient's bruises, well documented on Polaroid photos, were hickeys. Needless to say, they weren't. I then had to explain to the jury the difference between hickeys and bruises, and how I could tell the difference. (Tip: hickeys are punctate and reddish-purple. Bruises are darker and homogenous, with no little dots in them.)

    I never thought I'd be testifying as a hickey expert, but medicine takes you to some strange places.

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    Wednesday, September 06, 2006
    Fun with Treadmills

    You may or may not have seen this, but it's well worth a view. Better with the sound on.
    (via PJ)


    Zero To Sixty

    I had a lovely week off work, but my peaceful attitude was destroyed upon my return... as usual. Even though Monday was a holiday, it didn't feel like one; I dropped in to the office to review charts and suddenly realized I had a nursing home patient who was overdue to be seen (I had conveniently managed to forget about her, probably due to Vacation Brain). At the same time I checked the call schedule and saw that I was scheduled to be the hospitalist this week, AGAIN. I just did this two weeks ago, dammit. It's somebody else's turn. Throw in 300 spams in my inbox and a nasty sinusitis I managed to acquire on the trip back, and you can see that my attitude at the moment is not of the best.

    There is good news. After months of limbo, it is now a fact that my office is going to be moving to much posher digs than those we currently occupy. Our management has been wanting to do this for a year, but one thing after another kept delaying us - most notably a recalcitrant landlord who did not want to negotiate. However, at last The Firm has signed the lease and applied for approval of our remodeling plans. We will probably not move before February, but at least we're making progress. Once we have a definite move-in date, my next step will be making arrangements to get my brother's desk from the East Bay locker where it currently resides. (My brother is the proud owner of a beautiful, huge old wooden desk that he snagged when his employer redecorated and bought all new office furniture. I've wanted it for ages, but he was unwilling to part with it until he and his wife had a baby. The home office became a nursery, and the desk is now somewhere in Oakland.)

    More good news: since the start of the summer, I have been on a four-day work week. This means that while my Monday, Tuesday, Wednesday and Friday schedules are somewhat longer than previously, I have Thursdays off. It's wonderful. Now if I could just find something to do with my Thursdays other than drinking coffee and staring blankly out the window - though I do enjoy that. What I really should do is clean out the kitchen cupboards. Perhaps that will be this week's agenda.

    Now if I can just stagger through the rest of today, I will take my sinusitis home and put it to bed.


    The Heidi Treatment

    I stopped by V.'s office the other day along about Phone Call Time (similar to Twilight Time) to find her staring at one particular chart. The annotations on the message slip attached to it were so copious as to inspire a mental comparison to War and Peace... in case you're wondering, this is never a good sign.

    "I'm supposed to cure her," V. said grimly. "She's been in the hospital repeatedly, seen every specialist you can imagine, and her neurologist gave her mother my name. Now they're begging me to see her."

    I picked up the chart and started flipping through it idly. "What's her problem?" The chart consisted of copies of hospitalization records and studies. It was pretty thick for someone who hadn't even been to the office yet.

    "She's got all these neurologic symptoms nobody understands. She's too weak to walk. She was seen by Psych and they think it's conversion syndrome. I've never even seen anybody with conversion syndrome, have you?"

    I was impressed. Conversion syndrome was first described, if I recall correctly, by Sigmund Freud. Basically it's a phenomenon in which a person develops a physical symptom or problem for no good reason and no medical cause can be found. The idea is that it's a subconscious psychological defense that allows the person to avoid some overwhelming issue. (Think hysterical blindness, for example.) I've never seen such a case; it isn't a very common problem.

    "How long has she had this?" I asked, flipping through the chart.

    V. sighed. "A few years." Without going into details, the patient in question underwent some severe physical and psychological trauma while she was a college student and had had the problem more or less ever since. The family was unwilling to accept the diagnosis of conversion syndrome and was insisting that there had, simply had, to be some sort of physical explanation; hence the multiple visits to specialists and V.'s dilemma.

    I began to free associate, thinking of ways to miraculously cure someone with this type of problem. "Maybe she needs the Heidi treatment," I suggested as a memory popped into my head.

    "And what is the Heidi treatment?"

    "If you remember your childhood reading, Clara was Heidi's best friend who was unable to walk. She was stuck in a wheelchair until she went to visit Heidi and her grandfather in the Swiss Alps. A few months of goat's milk, fresh air and sleeping on hay and voila, she was miraculously cured and able to walk again."

    V. looked thoughtful. "Yeah, I think I remember that." (V. and I seem to have read many of the same books during childhood. I haven't asked her about The Five Little Peppers and How They Grew yet, but I'm sure that will be next.)

    "Well, there you go. Just get her a ticket to Switzerland and you're all set." I left before she could hit me with the chart.

    [Postscript: this happened a few months ago. At last report the patient is doing much better.]