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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    Friday, November 30, 2007
    Elmo, the Smoking Muppet

    Sometimes my patients will bring their kids along to their appointments, life being what it is; and understanding that sometimes you just gotta bring your kids along, I am generally okay with that. Once in a while I will be cursed with a kid who is convinced that this is all a plot and Mommy isn't the patient and I am going to stick them with a huge needle when they least expect it, and they shriek at the top of their lungs all through the visit (Reason #1 why I didn't go into Peds: crying kids), but usually all goes well. Today it went well.

    "The doctor's going to examine you in a minute, honey. Can you say aahhh? Just like the doctor did with Elmo?" My patient's two-year-old daughter beamed, opened her mouth and stuck her tongue out as far as it would go.

    "We watched a video yesterday where Elmo goes to the doctor," my patient explained. "I thought it would help get us through the visit." She continued in a singsong voice, half to me, half to her daughter: "And the doctor took Elmo's blood pressure and told him he was fine, but Elmo still had to get a shot."

    "And then the doctor told Elmo to quit smoking," I contributed.

    My patient laughed. "Yes, that explains his voice! It's the smoking!"


    Thursday, November 29, 2007
    You Only Think You Have Health Insurance

    There is an interesting - and cautionary - story in the Wall Street Journal today concerning patients with health insurance who can still face huge medical bills after hospitalization (there is a link to the article at wsj.com but you have to be an online subscriber to read it).

    The story focuses on one such patient who spent five months being hospitalized for a massive staph infection that nearly killed him. He endured septic shock, endocarditis of one of his heart valves (which had to be replaced) and the removal of his pacemaker (which was "encased in bacteria" per the article). He then went into cardiac arrest during a session of physical therapy and required implantation of a defibrillator. His medical bills totaled more than $2.7 million, only $1.5 million of which was covered by his insurance... because that was the lifetime cap on his policy.

    "Lifetime cap" means what it sounds like: the policy won't pay more than X amount of benefits during your lifetime. At 1.5 million dollars, this patient's policy was actually relatively generous: many policies these days have caps of $1 million or less. The article quotes an employee-benefits consulting firm, The Segal Company, as saying that average health-plan caps have not changed since the 1970's (they were $1 million then, and they're still $1 million today).

    The patient and his wife began investigating the individual charges on their bill and found - surprise - that they were massively padded. Example: they were charged $791 for compression stockings, which can be purchased for under $20 on the Internet (again per the article). This is standard procedure among all hospitals, including the ones where I work, because no insurance plan (or Medicare/Medicaid) will pay a bill at face value. All bills are massively discounted, up to 60%. Hospitals fight back by upping their individual charges to inflate the bill, hoping to recoup what they were owed in the first place. This is all fine and good unless the patient is paying cash and has no insurance coverage.

    Fortunately this story has a happy ending: earlier this week the hospital called the patient interviewed in the article, told him he qualified for their charity care plan and wrote off his entire bill - this of course after dunning the patient multiple times through phone calls, and after the Journal started investigating. The moral here, I guess, is to beware of catastrophic illness: you may outlive your insurance coverage. And check your policy.


    Wednesday, November 28, 2007
    Worry Beads

    Doctors sometimes acquire an odd assortment of tchotchkes in the course of their careers; conventions or drug reps are often a fruitful source for items which may or may not make practicing medicine easier, but at least will make you go "Huh?"

    My favorite of these oddball teaching aids has hung on V.'s office wall for years. It's a series of numbered wooden beads strung on a nylon rope; she got it at an endocrinology meeting. Graduated in size, the beads number from "3" (the smallest) to "20" (the largest).

    "What is this?" I asked the first time I saw it.

    "Testicles," she answered matter-of-factly.


    "You use them in testicular exams if you think the patient has hypogonadism." The numbers correspond to testicular volume - cubic centimeters or grams, she isn't sure. If you have an adult male with a 3, 4 or 5, you can be reasonably sure you're dealing with hypogonadism (meaning lack of testosterone/sexual development) because testicles are like breasts in that they enlarge in the presence of the appropriate hormone. Someone who does not have sufficient testosterone will have mini testes instead of the appropriate size.

    "What if the patient has a 20?" I asked. "Does that mean he has a problem?"

    "I don't think so," she leered at me.

    I weighed the string in my hands before hanging it back on the wall. "How often do you use this when you're checking a patient?" I queried.

    "Never," she shrugged. "I use them for worry beads."


    Tuesday, November 27, 2007
    The Terraforming of Mars

    I think this is pretty cool:

    This is an artist's visualization of what might happen if we were able to melt the polar ice caps on Mars and render the planet's atmosphere more hospitable to Earth life. It's one of Wikipedia's Pictures of the Day (they have a terrific series of pictures, by the way, on every conceivable topic).


    WW II In Gamespeak

    Just came across this via a link from one of Tim Blair's commenters. It is succinct and hilarious.


    Monday, November 26, 2007
    Thoughts On Lunch

    Here's a cute blog for you to check out: Landmarks at Lunch - it's a collection of reviews and pics of restaurant landmarks in Los Angeles. I am probably thinking about lunch (and landmarks) right now because my folks took me out to lunch today for my birthday: We went to the Spitfire Grill, a little restaurant in the Santa Monica Airport complex. My dad used to eat lunch at this place years ago, when I was a wee thing and we had first moved to Southern California (he was working for Douglas Aircraft at the time, in the field of Aerospace Medicine). In 1964 Aerospace Medicine was a viable career for physicians, and in fact he worked on Skylab and other stuff relating to the Apollo missions, but he eventually tired of the overwhelming bureaucracy involved in working for the government and switched to private practice instead.

    Douglas Aircraft was eventually sold to McDonnell Aircraft Corporation, and operations were moved from Santa Monica, but the airport remained and is now a private airfield. There used to be a very interesting museum here, the Museum of Flying, but it has closed temporarily - though the word is it will reopen in the next few months.

    Going back to lunch (yes we are), a subject that has been occupying me quite a bit in recent months is What to Bring to Work For Lunch. This is why: we moved in June. My office was formerly located across the street from Local Community Hospital, which had the endearing habit of feeding the staff physicians for free - not many hospitals do this today, I might add. When I was growing up my father was on staff at any number of hospitals in Orange County, all of which had doctors' dining rooms and would not blink at comping the doctor's tab or, for that matter, his (it was always his) family's tab. Suffice to say, my warm memories of Sunday lunch all involve hospital cafeterias (but this made sense; my father had to round on his patients anyway, and this allowed him to spend time with us and get work done at the same time. And, we got lunch for free. Oh, you crafty Dad!)

    But I digress. Again. So we are back to me, stranded, on La Cienega, also known in Los Angeles as Restaurant Row. One little catch about this situation is that almost every restaurant on said Row costs a great deal of money to eat at for lunch. One could not do this for long - say, more than a couple of days - without staring at one's wallet and screaming, "Where did all my money go???"

    I quickly realized it was time to brown-bag it. I equally quickly realized that the subject of What to Pack for Lunch involves Deep Thought and perhaps Purchasing Ahead of Time. I cannot get away with tossing some fruit and some cottage cheese into a bag at the last minute and shlepping off to work. Invariably I will scream "I can't handle this" when it comes to lunch, and run down the street to grab an overpriced sandwich at Starbucks, or (perish the thought ) order out. For the fifty-seven thousandth time.

    Here are my personal answers for this problem, and I realize that your mileage may vary, but I can only do what I can do. Herewith - Lunch, Interrupted (by the phone):

    • Hummus. I really like Trader Joe's brand myself. They used to sell a Roasted Pepper and Green Olive Hummus that I would have killed for: sadly, they no longer do, so now I dump regular hummus into the food processor with roasted bottled red peppers (drained) and green olives. This is very good on pita bread with sprouts or sliced celery.

    • Tuna fish. Oh dear God, tuna fish, how do I love thee? Let me count the ways. I love thee in the food processor with carrots and red onion. I love thee with sweet pickle relish. I love thee with onions, capers, black pepper and dill pickles. And I even kind of like thee with jalapenos and canned peas (no joke; a friend of mine once gave me this recipe, whispering that he loved it. I think it has to be one of those Secret Shame things). Pita bread, regular bread, salad greens... it doesn't matter, I will eat thee any old way.

    • Salad. If salad is to hold me, a) it has to be a really good (and really big) salad and b) it has to be accompanied by something else. Like good Greek-style yogurt or cottage cheese. And maybe a piece of fruit for later. Salad involves a lot of chopping for me, which is not a deal-breaker in itself, but it usually means that Monday is Salad Day so that I can prepare everything Sunday afternoon. (Celery, radishes, carrots, green onions... you get the idea. Let us not forget washing the lettuce, my least favorite chore.)

    • Soup. Soup, how do I love thee... oh wait, I've already done that. Well, soup is great. You have to prepare ahead of time by liking the right soup of course, but I love lentil soup which freezes very well, so that is not a problem. Other soups, such as black bean or vegetable, will do too; just make a big old batch of this stuff and freeze it in containers and you are all set for a while. Should you get sick of soup after one or two days, hey, it's in the freezer, so there is no hurry about finishing it. I have a wonderful lentil soup recipe I stole from Laurie Colwin which I make very frequently so that I can freeze it. This does not really involve actual measurements, but here goes:

    1 cup of lentils, a quart of water or stock, one clove of garlic, one onion, one carrot, one rib of celery. (Dice garlic, carrot, onion and celery.) Some canned tomatoes, or a spoonful of tomato paste, or a diced fresh tomato, or a spoonful or two of leftover tomato-based pasta sauce (you can throw any damn thing into the soup and it will taste fine). If you don't like tomatoes, they are not mandatory by any means, but I usually add a tomato-ey thing. A couple handfuls of diced green beans (or another green veg, such as broccoli rabe, spinach, or kale). I always add the green beans simply because I really like them. Cook above ingredients over low heat for two to three hours: If you want more soup, add more lentils and more water and expand the other ingredients if you want or need to.

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    Sunday, November 25, 2007
    Fingers and Bets

    Since I fractured my little finger I've gone back and reread Man from the South, by Roald Dahl. Mr. Dahl, by all accounts a rather strange man, had a gift for writing disturbing stories (Charlie and the Chocolate Factory, while very well written, is nothing if not what the MST3K robots would call "good old-fashioned nightmare fuel").

    In this story, which takes place at a resort hotel in Jamaica in the 1950's, a young American sailor agrees to bet his little finger for a Cadillac. I highly recommend you read the story if you have not done so:

    “Don’t you think this is rather a silly bet?” I said.

    “I think it’s a fine bet,” the boy answered. He had already downed one large Martini.

    “I think it’s a stupid, ridiculous bet,” the girl said. “What’ll happen if you lose?”

    “It won’t matter. Come to think of it, I can’t remember ever in my life having had any use for the little finger on my left hand. Here he is.” The boy took hold of the finger. “Here he is and he hasn’t ever done a thing for me yet. So why shouldn’t I bet him. I think it’s a fine bet.”

    The little man smiled and picked up the shaker and refilled our glasses.

    “Before we begin,” he said, “I will present to de referee de key of de car.” He produced a car key from his pocket and gave it to me. “De papers,” he said, “de owning papers and insurance are in de pocket of de car.”

    Then the maid came in again. In one hand she carried a small chopper, the kind used by butchers for chopping meat bones, and in the other a hammer and a bag of nails.

    Well, I disagree with the young man quoted above: You never know how much you use your little finger until you can't use it. Granted, I injured the little finger on my dominant hand, and the story implies the bettor is right-handed... but still.

    So my advice to you is this. Should a man who looks very much like Peter Lorre offer to bet you your little finger for a car, don't bet him... because you'll miss your little finger more than you think you will, and more important, because he doesn't own the car.


    Saturday, November 24, 2007
    HAHA LOL Etc.

    Loved this LOLpic, as any movie lover would:

    Funny Pictures


    All Hail the Sonic

    The first trip I took to Louisiana this year changed my life: I discovered the fast food chain known as the Sonic Drive-In. Sonics are wonderful. To begin with, they really are drive-ins; when my friend first mentioned them I thought she meant "drive-through," but I was wrong. To continue, they serve flavored drinks, the kind you usually have to track down at expensive theme restaurants (at least here in Los Angeles). Sonic, however, serves well-priced vanilla, (blue) coconut, cherry or chocolate-flavored sodas... not only Coke, but Dr. Pepper too! Who wouldn't want to try a cherry chocolate Dr. Pepper?

    Well, apparently me. That was just too much flavoring for my taste buds to cope with. But I did have a vanilla Coke at Sonic, and also a limeade, and they were fantastic.

    Last and most important is the Sonic food menu. They serve grilled cheese sandwiches, which is my personal test of a good restaurant. (The cliche goes "If a restaurant serves a good cup of coffee, everything else will be good." Well, for me that goes double for grilled cheese. Theirs is perfect, with nice thick bread and just the right amount of cheese.)

    And they also serve... be still, my heart... Tater Tots. Chili Cheese Tater Tots, no less. And they are properly cooked, with nary a soggy undercooked Tot to be found (no doubt plenty of boiling oil is involved in their preparation, but we won't think about that right now).

    After my first encounter with a Sonic, I announced to my friend and restaurant guide LA my intention to retire from medicine, move to the South, and open a Sonic Drive-In; she gently advised me that I might want to rethink that career move. Since then I have found that there are Sonics fairly near me in Glendale and Anaheim, so when desperate I can still get my Sonic fix. My fixation on the Sonic phenomenon was such that, when I returned to Louisiana two weeks ago for a quick return vacation, LA handed me a small cylindrical doll made of shiny gold fabric with little stuffed legs and a printed smiley face.

    "What's this?" I queried.

    "It's a Sonic Tater Tot," she laughed. "They were giving them away and I got one for you."

    Mr. Sonic Tot is now happily esconced on my dresser top, where I greet him every morning. I think everyone should have a plush Tater Tot doll... don't you?


    Friday, November 23, 2007

    The Firm closed the offices early today, being the day after Thanksgiving and all. The staff took off at the stroke of three, but I... am still here. (Clearly, my staff are smarter than I am.)

    I am still here because:

    • I have eleventy billion charts I am supposed to be preloading.

    • I have a couple of patients I really should call.

    • After completing - or so I thought - all my P4P crap, I was presented with a list of patients in a new category: Colorectal Cancer Screening. There are a hundred and fifty patients on this list. I have to find out if they have had any sort of colon screening, which involves pulling a hundred and fifty charts.

    • I need at least ten more CME hours for 2007, so I should be doing some online Pri-Med courses or something.

    What am I ACTUALLY doing? - playing Sudoku online and talking to V. And blogging. I cannot face the thought of doing any more work today.

    I think I'll go home now...


    Family Medical Leave Act: Good and Bad

    So, the Family Medical Leave Act. Let us speak of it. FMLA was enacted in 1993 with the purpose of giving workers more freedom to take care of kids and/or aging parents, as well as chronic health issues affecting employees themselves. Restrictions do apply; the Act is only available to companies of 50 or more employees, and before a worker qualifies for FMLA coverage he or she has to have been employed at the company for at least 12 months and have worked at least 1250 hours during that time. The coverage allows for up to 12 weeks of unpaid leave per year.

    The only relatives of employees who qualify for coverage are parents or children of workers - I had one patient who wanted to take time to care for her aging grandfather but this was not covered under the Act. Mostly, though, patients want this time for their own health issues. I have several patients who have applied for FMLA coverage. If someone needs time to recuperate from surgery or has ongoing appointments for physical therapy, chemo or radiation treatments, obviously this makes a lot of sense. Where things get trickier is if someone has a chronic disease and is taking time off at irregular intervals (red flags here would be something like fibromyalgia or chronic fatigue syndrome). Employers hate this sort of thing because it makes it very difficult to schedule workers if someone takes unplanned or intermittent leave.

    The potential for abuse here is clear: according to the article, one investigator found an employee who was using FMLA leave to start a landscaping business; the Pennsylvania Turnpike Commission refers to FMLA requests around holidays and weekends as "get out of jail free cards." I tend not to register patients for FMLA myself until I am very familiar with their medical issues, and employers are starting to request second and third opinions in some cases before approving coverage.

    Some employers use outside benefits providers to handle FMLA; this makes it easier for them because having a third party handle the paperwork and monitor requests removes the friction between employer and employee. If employees don't qualify they can't blame the employer for putting a spoke in their wheel.

    The Department of Labor is planning to revise the Act, but what form those revisions will take remains to be seen. Of note, though, when the department requested comments on the law in 2006 they were surprised by the sheer volume they received: more than 15,000 responses from unions, workers, companies and law firms. Clearly this is a hot button topic for everyone concerned.


    Thursday, November 22, 2007
    JFK Anniversary

    The news today made much of the fact that this year Thanksgiving falls on the forty-fourth anniversary of the JFK assassination. I brought the subject up over Thanksgiving dinner at V.'s. V. was in second grade at the time and has a vivid mental picture of the entire afternoon; she still remembers little details like the coat hooks in the cloakroom where the students were sent to pick up their coats (their school let out early that day after the news broke).

    I have no memories of the event myself, as I was born four days afterward, but my parents have told me their recollections of the weekend. My mother was in the hospital with a bad case of preeclampsia and my father was in the hospital too (it was a teaching hospital, and I was born during his internship year). My dad has always been a gizmo kind of guy, and this was in the days before hospital rooms had televisions in them, so he hooked up a little black-and-white TV in my mother's room. She said nurses were constantly popping into her room to catch events as they developed (I imagine her room was packed when Jack Ruby gunned down Oswald).

    I remember the twenty-fifth anniversary of the assassination, as I was in medical school at the time and we had a special presentation in pathology class which was based on a published article from the pathologist in the Dallas hospital where Kennedy was taken for his resuscitation effort. At least, I think that's who he was - I have been searching my files and cannot find my copy of the article, so apologies if I got it wrong. His reconstruction of the injuries, leading to his conclusion that there was no conspiracy and that Oswald really did act alone, was incredibly interesting.

    Next year will be Year 45 and I anticipate there will be more media stories about JFK than we got this year. It's odd to view this more as a personal milestone than a national event - but I think perhaps that always happens when a birthday coincides with a major happening. Imagine being born on or around December 7, 1941, for instance.


    Wednesday, November 21, 2007
    The Not Medical Post (Warning: Recipes Ahead)

    Sigh. I saw this interesting article in the Wall Street Journal today that I was going to blog about, regarding the Family Medical Leave Act and how employers/employees/the Feds are reacting to it. It's an interesting subject to me because I have to fill those crappy forms out for patients all the time. Not without reason; sometimes people, or their parents or their kids, simply need time off for chronic or recurring health problems. But apparently the Act as it stands is subject to abuse by patients (big surprise: Do you know how many times I have to explain to people that just because sick time is there, you aren't entitled to it if you aren't sick?)

    But the point is, I left the WSJ article at work. So no blog subject there. You will just have to wait to hear me pontificate about FMLA, which you know you will, because this is NaBloPoMo and I need a damn subject to write about, okay?

    So we will default to my favorite other subject, which would be food, and tomorrow is Thanksgiving so I feel entitled and even forgiven for writing about this sort of thing. Somewhere out there is a reader desperately looking for a side dish or appetizer to serve during the 2007 holiday season which will knock people's socks off, and this is your lucky day because I got your recipes right here. Try the Celery Casserole, or you could try this awesome Artichoke Dip which I stole from Simply Recipes.

    Here you go:

    *Two cans (12-14 oz each) of artichoke hearts in water (not marinade)
    *1 cup mayonnaise (not salad dressing; you could maybe use low fat mayo but dude, it's a holiday.)
    *2 cups shredded parmesan cheese
    *two pressed or minced cloves garlic, or 1/4 tsp garlic powder
    *couple handfuls shredded mozzarella

    Drain and chop artichoke hearts and combine with other ingredients. Pack into pretty microwaveable dish and nuke up to 5 minutes, stopping to stir if needed. Serve with water crackers or endive leaves or chips. It's easy, can be done in advance, and people always hoover it up (including V.'s 7 year old, who is not fond of artichokes as a general thing).

    Then we have Creamed Pearl Onions. I was press-ganged into making these by V., since I am having dinner at her place and this is one of those nostalgic dishes for her (and rightly so; everyone has their favorite holiday side dish. I will try to share a few more of mine before the end of the year). Anyway, she asked me to bring these onions because cream sauce is not her thing. I was happy to give it a go because last year I went to my brother's and his mother-in-law made excellent creamed onions.

    Pearl Onions: These are, essentially, baby onions (one stage past what are variously known as spring onions, scallions, or green onions, but a miniature version of what is sold in grocery stores in the mesh bag as Onions).

    This is what you do with them. Get your pearl onions (which will cost you a bloody fortune, by the way... easily more than a bag of REGULAR onions) and put them in a bowl and pour boiling water over them, let sit for one minute and then drain and peel. The peeling is fun as the little onions will pop right out of their skins like marbles. If you are lucky they will require no further cooking. (Try skewering them with a toothpick or sharp knife to check.) Update - they probably will need more cooking, but my recipe said up to 20 minutes, which is clearly too much. Try 7 to 8 minutes in a steamer.

    Then you make your cream sauce. I think these proportions will work: 1 to 2 T. butter, 1 to 2 T. flour, 1 cup milk or half and half, tad salt and white pepper. You can try freshening it with a small squirt of lemon juice or a dusting of nutmeg (you can use nutmeg with onions, right? Well, I guess we'll find out) but try to keep it simple.

    Melt the butter over low heat, stir flour in, let cook for a minute or so and then slowly whisk in the milk. Some recipes say you should heat the milk, but I don't think you have to... it does help if it's room temp or warm though. So measure out the milk and let it sit before you start to blanch the onions and you should be fine. I guess I should have told you this back at the start of the recipe. Oh well, that's why cooks say always read the recipe through first.

    Anyway, sauce is made, throw in the onions, let heat for a couple minutes if you have reason to think the onions need a little help. Or, put the onions and sauce in a casserole dish and top with buttered bread crumbs, then throw in the oven at 350 to 375 degrees for 20 minutes or until bubbling.

    Among these three I think you, the well-meaning guest, should be completely prepared. If asked tell your host it's an old family recipe... I always do.


    Tuesday, November 20, 2007
    "Put On a Happy Face"... Oh, Get Lost

    Today, after our latest office meeting about the importance of patient satisfaction and acclimatizing to our wonderful new EMR system and being upbeat and stuff, I sent this to the office staff en masse.

    Funny Pictures

    It was well received.


    Monday, November 19, 2007
    The Fog, and The Blog, and the Monday

    ...I'm a little depressed at the moment. Not because of the fog. I happen to really like fog. It's as thick as hell out there tonight, you can't even see the Century City office buildings or more than a block ahead of you. It adds a nice Humphrey Bogart, Raymond Chandler-esque atmosphere to the city. And hey, it's a great sound deadener too!

    I had ample opportunity to admire the fog this evening as I was driving around, first to the hopital to admit the patient I was handed on a platter at 5:15 p.m., then to the nursing home to see my poor old dementia patient. He was transferred there from Local Community Hospital after his wife took him to the ER today and announced she couldn't take care of him anymore (and let's be fair, she has her own set of problems, but her family and I have been working like mad to get him to move to their daughter's who lives out of state, but the wife has been fighting us tooth and nail. Because she apparently would rather dump her husband in a nursing home. WTF.)

    I think part of the problem is that even though I've managed to keep up with National Blogger Posting Month (so far, anyway), I keep coming across people who write much much better than I and manage to do so on a fairly regular basis. They have interesting topics; I have recipes and bits of medical advice. Well, that's what I know and I find it interesting, at least some of the time. And as they say, practice makes perfect. The whole reason I joined the project was because I needed something that would discipline me to write every day and learn to do a better job.

    Maybe it's that I am spending another week as hospitalist, a chore I loathe. I did finally email the head of my call group today to tell him that I don't want to do inpatient work any more, which made me feel much better. V. was wonderfully supportive about this.

    "I feel guilty about it," I whined.

    "Guilty? Where does guilt come in?"

    "Because Bob and Ray [not their real names] work their butts off taking call. They do so much more than I do."

    "Is that your problem, or theirs?"

    "Theirs," I admitted.

    "We're hiring more docs," she pointed out. "Let the newbies do it, it's their turn. You've done your share."

    Sometimes I really do need permission to say no. (Thank you, V.!)

    Suddenly I'm feeling somewhat better about things. Writing all this down just made me remember a quote from one of my favorite writers, Barbara Pym:
    Writing... really does take you out of yourself. I sometimes feel it lets you more into yourself, though, and really the very worst part.

    -- Less Than Angels


    Sunday, November 18, 2007
    Revenge of the Dachshund

    Ha! I just finally went and clicked over to Miss Doxie's website, which even though Dr. Mabuse has been linking to her forever I hadn't bothered to go and look at, and came across this post which made me shriek with laughter. Our family had a dachshund growing up, and I can say with authority that not only are they cute little buggers, they are also stubborn and vindictive - just like Bo. I needed a good laugh and that's exactly what I got: Miss Doxie is going on the links list.

    The Holidays Approacheth

    The countdown has started: the local radio station that plays nothing but Christmas music for a month prior to the holiday has begun playing Christmas music. (Every year when they start this I want to hunt down the manager so I can scream at him, "Dude! It's not even Thanksgiving yet!") The malls have put up all their decorations - except Nordstrom's, thank goodness. This chain of department stores consistently refuses to put up Christmas decorations until after Thanksgiving is over, for which I salute them.

    I'm gearing up for another week on-call at the hospital which is going to include Thanksgiving Day; I'm not leaving town this year, for which I am grateful (I hate traveling at Thanksgiving). I'll be going to V.'s for dinner and bringing celery casserole, a good standby holiday dish. It's kind of like a twist on green bean casserole but it is much, much better.

    Celery Casserole
    4 cups sliced celery
    1 can cream of something soup (I use cream of chicken)
    1 small can sliced water chestnuts
    1 small jar sliced pimento
    1 bag of Pepperidge Farm herb flavored stuffing or other herb stuffing, crushed to crumbs
    Butter, salt, pepper

    Blanch the celery in boiling salted water about 3 minutes, drain and plunge into a bowl of ice water (stops the cooking). When cold, drain celery and dry thoroughly (I usually wrap it in a dishtowel and put it in the fridge – you can do this part several hours ahead of time). DO NOT OVERCOOK THE CELERY. Combine with soup, drained water chestnuts and drained pimento and place in casserole dish (9 in x 9 in). Combine stuffing with some melted butter and sprinkle on top. Heat at 325-350 for about 40 minutes or until heated through.

    Guys in particular seem to love this. It doubles well and if you need to bring something to a holiday dinner, it's ideal because it can all be made in advance and then you just throw it in the oven when you get to your destination.

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    Saturday, November 17, 2007
    Combating Bedsores

    Recently Medicare announced that within a year it will no longer pay hospitals for treating certain "reasonably preventable" conditions, one of which is bedsores. This has spurred hospitals to develop aggressive programs to prevent them, such as playing music to remind the staff to turn patients every two hours. And with reason: decubiti, the medical name for pressure ulcers or bedsores, are among the most frequent, costly and dangerous of medical complications.
    Quote from the article:

    In elderly or disabled patients, sores can begin forming in as little as two to six hours, but pressure ulcers also can develop in much younger and healthier patients on the skin of the tailbone, back, buttocks, heels, back of the head, or elbows. Poor nutrition or dehydration can weaken the skin and make it more vulnerable.

    For a healthy person spending a routine night in bed, or even on a futon or sleeping bag, this sounds unlikely... but in a weakened patient who cannot move themselves and who may well be dehydrated these sores can form with frightening speed. They can become infected and have been known to kill in themselves (think Christopher Reeve, who died of sepsis from an infected bedsore). The article provides some interesting tips developed to remind staff to keep checking patients, which is really the single best way to prevent this complication.


    Friday, November 16, 2007
    Thrift Store Boots Update

    Per my Louisiana friend, she returned to the Goodwill to try to claim them for me and they are nowhere to be found. Sob. I really liked those boots.


    Bring Back the Luddite Movement

    I've made some mention of our paperless chart system, or EMR project, here and there in recent months. I do see its advantages - really, I do - but it certainly isn't perfect. When the system goes down chaos ensues, and for months it would crash nearly every week. The recurrent crashes were finally fixed with an intensive overhaul of the software, but this morning looked like being another such episode; fortunately it didn't last long.

    When I logged on early this morning I found the system incredibly slow, not only with the EMR but with loading my Microsoft Outlook as well. Twenty minutes or so later, it froze and I called the help desk. By the time I got through to somebody at the desk I had tried my one basic maneuver of logging off and back on, and the problem had stopped. Later on I found out that I wasn't the only user dealing with this issue; it was the laser wireless transmitter up on the roof that had caused the problem. This "unhackable" laser sounds great on paper, but in practice it's a royal pain. What threw it off this morning? -- it was the fog.

    Yes. Fog. Gee, I can't wait till it rains... let's see what happens to our records system then! Other outages have been blamed on pigeons (apparently they knocked the laser out of kilter or something). I emailed a snarky comment to V. about this episode: "It doesn't matter if it's unhackable if it's unusable."

    We have been promised a switch to good old-fashioned optic cable instead of the unreliable Buck Rogers laser system, but it hasn't happened yet. I hope they hurry up before the rainy season gets here.


    Thursday, November 15, 2007
    Well You Don't Know Me But You Don't Like Me...

    ...Say you could care less how I feel...
    But how many of you that sit and judge me
    Have walked the streets of Bakersfield?

    I do love me some good country music. And this is mighty good. My friend LA introduced me to Buck Owens during my recent vacation and I just went, wow. "Act Naturally" and "Tiger By the Tail"... what more could you ask for?

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    Wednesday, November 14, 2007

    The first day back at work is always painful: Today was no exception, though it was more literally painful than is usually the case. As I was getting out of the airport shuttle van Monday night I managed to catch my little finger in the door and wrench it severely. It started swelling immediately and was an interesting shade of black and blue by yesterday morning. I cannot bend it at the proximal joint. Fortunately typing is not a problem, in fact, it's much easier than holding a pen.

    Figuring I might as well know the awful truth about the state of my proximal interphalangeal joint, I phoned up our X-ray tech who told me "Come on down." I descended to the x-ray suite, presented my pinky for inspection and soon found myself seated in a chair with a lead apron flung over me.

    "You want two views or three?" she asked.

    "Better make it three." Click, click, click and we were done. On review it looks as though I may have a small nondisplaced chip fracture in the PIP joint, so we sent the film to a radiologist for an expert opinion and I phoned up the hand surgeon's office. They are sending me a splint for my pinky via interoffice mail. If that doesn't help I may have to actually go and see the guy, but I'll try this first.

    Tuesday, November 13, 2007
    Conversations in Checkout Lines

    So today I'm shopping for milk and such to restock after my week off, and as I am standing in line waiting to check out, behind me I hear this woman's cell phone ring. Her conversation, I swear it, goes like this: (boring parts edited out)

    "Hi, yes, you don't have to pick up Sarah. I picked her up from the therapist's and took her to work with me. They said she only gained one and three-quarter pounds this week, so they were asking her about her caloric intake, what happened, and she said she was just careless..."

    So lady, I am deducing from this conversation that you have a daughter with an eating disorder. Question: Why would you want to talk about this in a supermarket checkout line?? Where anyone can hear you?

    On a funnier note, a few weeks ago I was in another store waiting to check out and the older gentleman in front of me had two individual Yoplaits plus a small cardboard case which I figured from the conversation contained another dozen. "The manager says there's twelve in that one," he informed the cashier. "They're all the same flavor. Boston Cream Pie. That's fourteen."

    Of course, I had to ask. (My father would have done the same; it's disconcerting to realize that I get more like him the older I get.)

    "What happens if you get tired of that flavor?"

    "Well, I've been eating them for two years now," he retorted. "I don't think that's going to happen."

    "Oh, okay," I managed.

    "Sometimes I get the lemon meringue flavor," he confided, "but I don't like the fruity ones. Ugh."

    You learn things about people standing in checkout lines. A friend of mine once recounted the story of standing in line late at night behind a haggard-looking couple checking out a lot of chocolate frosting. It was pretty clear what they were going to do with it.


    Monday, November 12, 2007
    Can You Freeze It?

    I never used to use my freezer much: It was mostly a repository for sad, unwanted bags of edamame and chicken breasts that had been bought in a surge of good intentions and hurled into the freezer, undated, to die a slow death of freezer burn. I knew I ought to use my frozen food but I could never remember to thaw it in time for dinner.

    These days I have become better about using what's in my freezer, thanks to a couple of good habits I've picked up from friends and family. First came the purchase of a Sharpie pen, which I keep in the kitchen next to the fridge. I have trained myself to use it to write the date of purchase on everything I buy just before I put it into the freezer. This has helped a lot, as I now never have to stare at something and wonder if I'm playing Russian Roulette by thawing and eating it. Also, of course, if I have multiple bags of the same thing I can use the oldest one first.

    I got another good idea from my brother when I was visiting him last year: he pulled some pork chops from the freezer for dinner and I noticed that they were in a vacuum-sealed freezer bag rather than in regular plastic wrap or store wrap.

    "Do you have a FoodSaver?" I asked.

    "Yes, and we use it all the time," he answered, and went on to explain that he and his wife often went to Costco and that the FoodSaver allowed them to make bulk purchases and freeze them. This impressed me, since they face the same problem I do: how to shop in bulk when you only have one or two people to shop for. I gave the matter some thought and wound up purchasing a FoodSaver from Amazon, half wondering if I would ever use it.

    I do, and it works. Once I'd used it a few times I started making larger recipes and freezing the leftovers with great success. I don't use it for everything - I freeze soup quite often, as it makes a good work lunch, and I usually use Tupperware or other lidded plastic storage bowls for that. Lots of things freeze well in ziplock bags, too (pasta sauce does very well in ziplocks). But for freezing meat or chicken, or baked stuffed potatoes (which freeze really well, BTW), I think the FoodSaver does an excellent job.

    As for remembering to thaw things... well, I'm still working on that one, but as long as I remember to move the food into the fridge the night before I want to eat it, my system as a whole works pretty well. I've also found that when I freeze more dinner-ready foods it's easier to remember to use them than it is to remember to thaw a solid block of frozen chicken.


    Sunday, November 11, 2007
    Late Anniversary

    I finally got the archives back online and realized, good Lord, I've been running this thing for five years. I started back in October 2002. For all you faithful readers (that would be maybe two or three of you) - thanks!



    I needed this vacation badly; fatigue has been my watchword lately, it seems. The summer flew by unnoticed taken up mostly by work (even more so than usual). What with our EMR (electronic medical record) project, my partner taking three weeks' vacation and the looming "pay for performance" deadline the last two months have been completely insane.

    I hope the rest of 2007 will be better: now it's MY turn for vacation, I have very few meetings scheduled for the next month and I finished reviewing my P4P list, so at least that's off the table. P4P, or "pay for performance," is one of those bureaucratic chores that make primary care doctors' lives so much fun. Insurance companies love to dream up highminded ways to improve care; if they incidentally make the practice of medicine more difficult in the process, that isn't their problem. The premise behind P4P is that doctors who give good care should be rewarded with higher pay, which seems reasonable. How do you know which docs give "good care"? - the ones who do the most mammograms and Pap smears, of course. Not to mention keeping the cholesterol and glycated hemoglobin levels of their diabetic patients within certain mandated boundaries. It's all about managing chronic illnesses these days.

    This sounds logical, but the stumbling block here is trying to keep track of the patients who don't get their mammograms (or other screening tests) and don't come to the doctor. Most do, of course. I think most patients want to stay healthy. But if one of my patients has decided that mammograms are too painful an ordeal and she doesn't want to do them, it not only puts her health at risk, her decision now reflects on me. With enough noncompliant patients I get pushed down below the benchmark level (and this information gets published in local and national media, so it matters) and I may now be faced with a pay cut if my patient statistics don't meet the benchmarks set by the all-knowing insurers. Insurance companies pay a bonus of anywhere from two to, I think, ten or twelve cents per patient signed with the group if you meet their benchmarks. If you have thousands of patients signed up that means a lot of money is at stake. If we don't meet the benchmarks the group doesn't get the money and the doctors within the group who didn't get their patients' cholesterol (or other clinical care marker) controlled will be financially penalized.

    This means that I usually spend the last few months of the year frantically tracking down patients to get them scheduled for studies. I have patients on my list whom I have never seen who have been assigned to me for years. They may live out of area, or they may be seeing another doctor on their spouse's insurance - it doesn't matter, if they are assigned to me I am responsible for them, and if we don't have their data I get dinged.

    A while back I got an email from a patient with the title "Why are you disenchanted, Doctor?" She genuinely wanted to know. I emailed her back thanking her for writing and telling her that while I loved the practice of medicine, there are bureaucratic aspects to it these days that are making it less and less fun and told her that I planned to write about those issues. This is an example of what I meant.

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    Saturday, November 10, 2007
    Good Vacation

    My friend lives in Central Louisiana and the thrift shopping here is awesome. That's a large part of what we did yesterday. Thursday night we went to a "Christmas Open House" event on the main street of her town; I thought it was too early for Christmas, but I was wrong. The homemade decorations, the lights, the Christmas sweaters... it all revived some long-ago childhood Christmas memory of visiting my grandparents in my mother's Tennessee hometown. Just lovely.

    I found a wonderful pair of boots in the Goodwill that didn't have a price tag on them - the woman at the checkout counter wouldn't ring them up, saying that they had to be priced, so we are going back to get them today. I hope they're still there.


    Friday, November 09, 2007
    Blind Spot

    No, this isn't a metaphor for anything. It's a literal blind spot, and we all have one in each eye. I tracked down this website, which nicely demonstrates the phenomenon, for a fellow blogger who's been having some eye problems recently. The learning point here is that if you develop a partial visual deficit, in time your brain will learn to ignore it and "fill in" the missing piece in your field of vision. If you go to the website and perform the simple experiment there, you will see what I mean.

    The retina in the back of your eye is a sheet of nerve cells that pick up energy from light coming in through the front of the eye; the individual cells join together to form the optic nerve, which leads to the brain. The optic nerve is in fact the only part of the brain that can be visualized without surgery; when your doctor looks in your eye, a big part of what he or she is looking for is the optic nerve, which can tell us if the brain is under pressure (think brain tumor). The blind spot is the point in the retina where the optic nerve leaves the eye to travel to the brain, and it's "blind" because there are no nerve cells there - the gap where the nerve leaves the eye socket leaves a deficit. So we should notice two gaps or deficits in our visual field, one to the left and right of center, but we don't. Binocular vision solves most of this problem, but even using one eye you won't notice it unless you have something very specific to use as a landmark. That's why the experiment linked above works.

    I find vision incredibly interesting - for instance, why do we see in black and white at night and in color only when there is more light? The retina contains two kinds of cells, rods and cones. Rods are more sensitive to light than cones are, but cannot sense color. In limited light conditions, therefore, the cones will not fire but the rods will. We can thus see, but only in black and white.


    Thursday, November 08, 2007

    I am off for a few days' vacation, but I will try to keep posting. I leave you with a link to a site I can't seem to stay away from: the LOLcats with cute animal pictures and captions galore.

    Here's my favorite.

    lolcats and funny pictures -

    There's also FreeRice, an online vocabulary game that allows you to donate rice through the U.N. World Food Program. The more words you get right the more rice you donate. I found it great fun - give it a try.


    Wednesday, November 07, 2007
    Right or Left Brain?

    A friend of mine sent me this link a while back but I forgot to post on it; then Andrea Harris' post reminded me. I think it's pretty cool:

    The gist of it is, if you see the dancer turning counterclockwise you're right-brained; if clockwise you're left-brained. (I included the original link above in case the dancer isn't moving; I may have screwed up somewhere.) The article says that if you focus you can see the dancer reverse position, but I can't manage that. I think I must be stubbornly right-brained, which comes as a bit of a surprise; I thought I was more left-brained.


    Tuesday, November 06, 2007

    As I was reviewing referrals tonight I learned a new term for infertility treatment: "procreative management." Then I thought, couldn't that phrase be applied to the traditional procreative method as well? It really isn't specific enough.

    "Honey, I can't make the Procreative Management conference tonight. I have a headache."


    Monday, November 05, 2007
    MCJ Rocks

    Chris Johnson is a scream. Check out the latest post, featuring church signs who want to convert to Catholicism.



    I saw Wicked yesterday with my folks and really enjoyed it. I tend to have strong feelings about most modern musicals (meaning: I don't like them), but I did like this show very much. The writing is clever, there is a strong storyline and the acting and singing by the cast were quite good. The sets and effects are amazing, but it was a pleasant surprise to see a play that didn't rely on pyrotechnic special effects to sell itself.

    I first realized the musical as an art form was in serious trouble about fifteen years ago when I saw City of Angels (and yes, I know that's a pretentious sentence; bear with me). In case you don't know, City of Angels is a musical about a mystery writer struggling with the task of turning one of his books into a movie script; the plot shifts back and forth between the writer's real life and the plot of his film, and the "film" side of the stage is in black and white. The concept, and the set, were great. The songs and the actors' singing were astoundingly disappointing. This was a musical I'd really been looking forward to seeing, and I walked out of the theater thinking This thing won awards? Why?

    Then I saw Cats. There's three hours of my life I'll never get back. As for Les Miz, the only decent song in it was "Master of the House"; the rest of it left me cold. In every case my problem with the shows was the Big Concept idea they were all based on - that, and the lousy songs. Why is it that nobody can write a catchy tune anymore? By way of contrast, last summer I saw that old warhorse Oliver! for the first time and loved it. The reason: the songs. I knew the standards "Consider Yourself" and "As Long as He Needs Me" were from the show but I had no idea that "Food, Glorious Food" and "Oom-Pa-Pa" were, too. These are standout songs, with great tunes and good lyrics. Yes, the plot is silly - Dickens relies too much on coincidence anyway, but the musical adaptation even more so since they had to compress it into a two-hour show - but it doesn't matter. It doesn't matter because you're sitting there waiting for the next song, the next great song.

    The choreography helps too. Let's face it, there's a big difference between good old-fashioned chorus dancing and the vague leaping and twirling that passes for choreography these days. This goes back, once again, to the songs as the source of the problem because if you have a strong tune and good rhythm it helps the choreographer immensely. Otherwise you just have to settle for looking arty, and let's face it, nobody goes to a musical for the intellectual experience. Well, okay, I'll give you Sondheim. His stuff is usually enjoyable and the books and plots are always good (I loved Sweeney Todd and Into the Woods). But there's only one Sondheim, and a surplus of Adam Guettels. Don't get me started about Light in the Piazza.


    Sunday, November 04, 2007
    It Was the Hollandaise

    Anatomy of a food poisoning outbreak, from the L.A. Times. The author, who suffered a nasty case of salmonella from a restaurant meal, does a good job of explaining how the Department of Public Health handles outbreaks of foodborne illness. To his surprise, it wasn't the sushi he had for dinner that made him sick.

    In a similar vein, I recently had a patient who had been traveling in Jordan on business present with two weeks of diarrhea. I ordered stool samples, usually the first thing you do in this sort of situation, but no antibiotics as he had no fever, no blood in the stool and no vomiting. In many cases antibiotics are not indicated for gastroenteritis and can even worsen the problem if you have, say, certain types of E. coli, leading to hemolytic-uremic syndrome and kidney failure. The next day he emailed me with an article he'd found describing the high level of cryptosporidium (a parasite) in the Jordanian water supply. I congratulated him: he'd diagnosed his own illness. The stool studies came back negative, indicating he'd cleared the parasite (as healthy people generally do). Happy ending.

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    Saturday, November 03, 2007
    "The More You Tighten Your Grip...

    the more star systems will slip through your fingers."

    This is merely the latest in a succession of withdrawals by various parishes and dioceses from the Episcopal Church. I find this truly tragic; to watch a denomination with a long and well-regarded history self-destruct is a very difficult thing. I do believe that the TEC leadership has brought this on itself; it's been a long and nasty development and it's a long way from being over. I have no idea what's going to happen next. It's entirely possible that Bp. Duncan will be kicked out of TEC, but at least he'll have the satisfaction of knowing that he made a deliberate choice to support his diocese. Should TEC decide to proceed with their threat to "discipline" (i.e. fire) Bp. Duncan, my take on it is that it will accelerate, not inhibit, the decision of any other congregations or parishes that might be teetering on the brink of deciding to leave.

    But, of course, I could be wrong.


    HMO Medicine

    funny pictures

    Haha, it's funny. Trust me on this.


    Friday, November 02, 2007
    All Souls'

    I try to keep track of my patients who have passed away over the course of the year and remember them on this day. It's something I like to do to keep them in my memory. In the whirlwind of medical practice, sadly, it's all too easy to forget about the elderly patient who died yesterday or last week as we cope with the onslaught of new, live, sick patients demanding our attention.

    My patient who died most recently was a sweet elderly woman with terrible emphysema, who developed a respiratory infection and then, sadly, colitis from the antibiotics used to treat it. She shuttled back and forth between the hospital and nursing home before we finally got hospice involved and focused on keeping her comfortable. I can say that her last days were happy ones, as she was able to relax and knew the staff was there to take care of her. She dreaded going back to the hospital.

    She died while I was out of town, rather unexpectedly - an odd thing to say about someone on hospice, but she looked quite stable when I went to see her before I left on vacation.

    I think of others over the years: the patients whose autopsies or funerals I have attended. The young man (in his twenties) found dead in his home of a catastrophic asthma attack. The suicide - an unbelievably sad story - a young woman who had found out her boyfriend was cheating on her. I still remember that she came to see me for a urinary tract infection just a few days before she was found dead, a basic add-on visit. I was with her just three or four minutes, giving her a prescription; after I got the news I ran that visit over in my head many, many times to see if I'd missed anything. She seemed exactly as usual. When the coroner called five days later, she had been found dead with the bottle of antibiotics nearby... that's how the coroner got my number.

    Death is part of practicing medicine; I think most doctors don't handle death as well as we might, either for the patient or for the family. By remembering the dead, I think - I hope - that I can do a better job with the living.

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    Thursday, November 01, 2007
    NaBloPoMo, Here We Go

    To explain the title: apparently there is this blogging idea, or site, called National Blogger Posting Month. The idea is simply that you post every day throughout the month of November; I heartily applaud it, speaking as a recalcitrant blogger. It should inspire or prod me to post more.

    So, last night was Hallowe'en, yes? Up till last year my Hallowe'ens were extremely quiet, living as I do in a neighborhood where there are not a lot of little kids. Last year one of my partners in The Firm invited me to help her and her husband hand out candy, dinner thrown in. It turned out to be the epitome of the warning that "there is no free lunch" -- or dinner, in this case. She lives in Hancock Park, which is one of the oldest neighborhoods in Los Angeles, and one of the few "Old Money" locales in this city. It is a beautiful, but in no way a glamorous neighborhood - no movie stars live there, at least none that I know of. Bankers and such, however, do. Somehow the word has gotten out that (in addition to being a safe neighborhood) the Hancock Park denizens are generous types and decorate their houses a lot, and as a result families from all over the city drive or even bus their kids in to go trick-or-treating. The population density on Hallowe'en night, as a result, rivals that of Hong Kong or Manhattan.

    Last night was my second year helping to hand out candy. As far as I'm concerned this beats the West Hollywood Hallowe'en Parade by a mile, not that that isn't fun, but this can be accomplished in more comfort. Plus, you get to see the cute kiddies' costumes as opposed to the guys in chaps and no pants with their uglies hanging out (no exaggeration; I have been there and seen that). A quick poll showed that Disney princess outfits among the girls are quite a hit, and Spider-Man (both red-and-blue good and the all-black BadSpidey) among the boys are big. Ladybug costumes and Tigger onesies for baby girls and boys were the big winners, also fairy costumes with flashing lighted wings for little girls. We saw a few Simpsons outfits and some very good homemade ones - most notably a Rubiks' Cube - and a couple of bad ones. A standout in the latter category was the pregnant trick-or-treater in a clingy black dress, and I wish I were kidding. I mean, I'd be the first to admit that I trick-or-treated a few years past when I should have quit, but that was ridiculous. Another was the overgrown ghost in a sheet - not a traditional sheet, though; it was a flowered sheet in DayGlo colors, and did I mention he was at least six feet tall? I leant against the door frame giggling helplessly after he left.

    Quick statistic: we went through 3600 pieces of candy in three hours. (Though we handed out 3 pieces of candy per petitioner.)

    "In MY day," I grumped, "each kid got only one piece." "Well, we're generous," shrugged my host, so I bit my tongue. After all, it wasn't MY candy.

    No candy cigarettes were to be seen though (sigh, they were my wicked favorites as a kid). I guess some things are just beyond the pale these days.