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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    Thursday, July 31, 2008
    White Trash Nicoise

    Salade Nicoise is one of those classic summer recipes. It exemplifies the more approachable side of French food: simple to make, not fancy, just really good. You can pay $15 for a plate of it in a bistro or you can make it yourself for a lot less. The basic ingredients are potatoes, green beans and tuna - you don't have to use tuna; I know one excellent food blogger who likes his with grilled swordfish - but this is my Nicoise. And we are not using the grill, we are going with canned tuna. You can feed up to six people with one can of tuna! Here we go:

    First start with the dressing. Get a jar and put in some olive oil and red wine vinegar - or you can use lemon juice. Proportions should be about twice as much oil as vinegar. Peel a garlic clove and cut in half and add to jar. Add some pepper and mustard (either dry or prepared is fine). Shake it up and set aside. You do this first to allow the garlic to infuse the dressing.

    Get the potatoes boiling. For four to six people I'd suggest five medium potatoes. Give them about 20 minutes (you don't want them too soft), drain, cool and peel. Slice them up and throw in a bowl.

    Prep the green beans while the potatoes are cooking, cut in bite size pieces and steam until done. You will want about three generous handfuls of beans, depending on how many you are feeding and how much you like beans. The balance of the salad can be either in favor of the starch (potatoes) or the green (beans); it is up to you. When beans are done, cool under running water, drain and throw in the bowl with the potatoes.

    Somewhere out there I hear a voice raised: "Isn't a proper Salade Nicoise plated?" Indeed yes, it is what is known as a composed salad, and you can take the time to build a pretty construction out of it if you like. We are not going to do that. Now drain the tuna (12 ounce can), flake it and add to the bowl along with some freshly ground pepper. Put several spoonfuls of capers on top. The capers really make the salad. Now get your dressing and dress the salad somewhat generously. You don't want to drown it, but the potatoes will drink up a fair amount of dressing. Start low and then add a little more if you need to. Toss the salad (gently! You don't want to mash the potatoes) and serve.

    A classic Nicoise contains anchovies, but I really don't like them, so I left them out. It will also contain hard boiled eggs, which I didn't bother with today - it was just me for lunch - but I do think the eggs are a good idea as they will stretch the salad. Just serve a halved egg on the side of the plate. You can also serve the Nicoise on salad greens, which will stretch it further and up your vegetable intake. Leftover salad makes a great work lunch for the next day.

    Some thoughts on capers: I love them and they are a great addition to this salad. If you like capers, try to buy the biggest jar you can find and you'll save money. I actually found a one-quart jar of capers at Surfas, a restaurant supply store. It will probably take me the rest of my life to finish it, but hey! Cheap capers!


    Wednesday, July 30, 2008
    Don't Bring Me Down

    I learn from my patients. I think most doctors do, if they pay attention. This past week I saw a patient for something very basic - a blood pressure check - but on reviewing her old records she began to tell me about the terrible dermatitis she'd had in her ears for a long time. I don't mean ordinary itchy ears, I mean something severe enough to weep or bleed. She saw a lot of doctors for this and tried a lot of medications, till she saw an ear nose and throat specialist who finally figured out the problem.

    She was allergic to down. As in feathers. Her pillows, her comforter both contained down; she went home, bagged them up, got rid of them and her problem disappeared. This story impressed me quite a bit.

    "I know lots of people are allergic to down," I commented, "but I thought it only gave people respiratory symptoms or itchy eyes."

    "No," the patient responded definitely. "This guy was a genius. He said down was causing my ear problems and he was right."

    This is the sort of thing I try to remember, because you never know when someone with really irritated ears is going to walk through the door.


    Tuesday, July 29, 2008
    Morbid Memories

    Recently on GruntDoc I came across the following amusing story:

    GLENDALE, Wis., July 23 (UPI) - Patients at a Milwaukee-area hospital say the last thing they want to see while facing surgery are vultures perched outside their windows.
    Yet, that's the view from some patients' rooms at the Orthopedic Hospital of Wisconsin in Glendale, Wis., the Milwaukee Journal Sentinel reported Wednesday. It said patients about to go under the knife can watch up to six turkey vultures sitting on ledges of the three-story building.

    This brought back memories of the hospital I worked in as a medical student in Camden, New Jersey. The residents' call rooms had a lovely view of the cemetery next door; on moonlit nights I used to wonder if the zombies would be coming for us. I also recall a memorable post-call breakfast there during which a funeral home's van pulled up and the staff loaded a sacked-up body into the back of the vehicle (the doctors' dining room looked out on the ambulance court). Ah, good times.


    Wednesday, July 23, 2008
    Netflix Review

    Rejoice, readers: it's another useless film review from Dr. Alice. Lately I seem to have rediscovered my interest in watching movies. When I was in medical school in Philadelphia I was lucky enough to be within walking distance of a South Street video rental store which specialized in art films and the esoteric; I worked my way through a lot of Ealing comedies and early Peter Sellers films back then. I've been a Netflix member for a while but the DVD's would sit for months before I managed to watch them. I think I've seen more movies in the past six weeks than I did in the previous year.

    At any rate, I suddenly realized that the films I've seen recently share one characteristic: a treasure hunt of some type figuring into the plot. This may be the focus of the film (National Treasure) or it may get relatively little attention compared to other plot points (The Rundown) but it keeps cropping up. So let's compare and contrast.

    National Treasure - the whole movie is one long hunt for a treasure hidden during the Revolutionary War, rather cleverly done. I enjoyed it. Extra credit for the presence of Nicholas Cage, whom I like. I keep thinking of him as the modern version of James Stewart. Also liked the location shots of downtown Philadelphia. Downside: Cage decides to steal the Declaration of Independence and pulls it off in just a few days?! Did he and his sidekick get all their fancy surveillance equipment from the Acme Company that supplies Wile E. Coyote? And did they get it on credit? Oh well, never mind.

    The Librarian: Quest for the Spear - a very pleasant surprise. This film, a parody of the Indiana Jones type of adventure movie, stars Noah Wyle of ER as a guy who's been in college for fifteen years and knows, literally, everything. He becomes the librarian of a top-secret library containing the Ark of the Covenant, a unicorn and the Holy Grail among other things (the library support staff consists of Bob Newhart and Jane Curtin, both of whom are great). When the Spear of Destiny is stolen he has to go after it, develop self-confidence, use various bits of esoteric knowledge he's acquired in the course of his studies, etc. Extra credit for the great cast and the humorous take on the plot. Wyle gets a couple of good lines in. My favorite, uttered after he's been trying to figure out what dialect an Amazonian tribe is speaking: "It's Portugese! I was overthinking it!" Downside: terrible special effects. Well, it's a made for TV movie. Would be good for kids.

    The Pacifier - tough SEAL officer Vin Diesel guards/babysits five kids while hunting for a missing secret missile guidance program, eventually loses his tough persona and bonds with the kids, etc. You can write the script on this one yourself: pleasant but predictable. Upside: an annoying little bedtime jingle he has to sing to get the toddler to sleep turns out to be a classic "in plain sight" clue to the location of said secret program. Downside: not only is this plot reminiscent of The Sound of Music, the writers actually worked a performance of Sound of Music into the movie. Gah.

    The Rundown - best of the bunch. Stars The Rock, or Dwayne Johnson, or whatever he's calling himself these days. He's a sort of glorified repo man who really wants to be a chef; the opening scene has him taking notes on recipe ideas while waiting in his car on a stakeout. Loved it. A local criminal hires him to go down to the Amazon and fetch back his son, who's there looking for a priceless relic. When Rock gets there he finds himself in a gold mining town run by Christopher Walken, who's also after the relic. Things escalate from there and the film ends with a classic Western shootout. The actual finding of the relic doesn't take that long and is almost a side issue. The real treasure here is Walken's performance; he plays the owner of the town like Colonel Kurtz on LSD. The scene where he lectures a bunch of armed thugs on the Tooth Fairy is priceless. Downside: there isn't one. Rent this movie.


    Tuesday, July 22, 2008
    Just Because It's Typed, It Doesn't Mean it's Readable

    The electronic medical record system has made things much easier for the specialists in our group, who formerly made entire careers of complaining that they never got timely access to labs or legible consult requests on the patients who were sent to them. Now that all the docs in the group have access to the charts, if you have a question you can just dip into the chart and read the notes and labs. I have to admit that this is an improvement, as is the fact that all notes are now legible (because they are typed). One problem still remains, however: no one has yet been able to solve the odd lingo that doctors create for themselves while taking notes. Abbreviations save time and minimize typing but often are understandable only to the person who created them.

    V. recently sent me a puzzling notation she'd picked up from the chart of a patient on whom she'd been consulting, wondering if I could decipher it. The notation in question read:

    NF - a little fruit.

    I'll spare you the speculation we went through on that one, until I finally realized that NF stood for "nonfasting" and "a little fruit" referred to what the patient had eaten that day. (If you're checking cholesterol and blood sugar, this could be quite relevant.) Once you figure it out it makes sense, but a better solution here would have been to use the QuickText application. This allows you to preprogram various abbreviations, so that if you typed .nf and hit the enter key you'd get "nonfasting" typed out as a full word.

    But then we'd have missed all the fun of trying to figure it out.


    Friday, July 11, 2008
    You Be the Judge

    Here's an interesting scenario: the "King of Spam" is being sentenced in court and one blogger is inviting commenters to submit their ideas for appropriate sentencing. Robert Alan Soloway is apparently only the second person to be sentenced under the 2004 federal law against sending spam and is estimated to have sent 90 million emails. (One commenter who used to run a mailserver suggested drawing and quartering Soloway.)

    The defendant's attorney is arguing that Soloway suffers from "oppositional defiant disorder" for which he takes medication and can't help himself when it comes to defying the law. Therefore he deserves a lighter sentence. Gee, I never knew that being a jerk merited extra consideration when you've broken the law repeatedly...

    (h/t Instapundit)


    Thursday, July 10, 2008
    Last Weekend

    I'm sitting here coping with telephone calls tonight, so I might as well take a few minutes to tell you about last weekend (Fourth of July holiday weekend) and how I spent it with the Southern Mafia. Let me enlarge on this.

    The daughter of old family friends - in fact, I went to school and to the prom with her elder brother - got married at my parents' house last weekend. They (my parents) have a lovely yard with a bricked patio and a gazebo, and she had asked years ago if she could get married there someday. They told her, "Of course!" Which only goes to show, never make a sentimental promise that you aren't willing to keep.

    But I kid, at least to a certain extent. My folks went to some trouble performing building and grounds upkeep and planting flowers prior to the wedding, but then my mother said optimistically, "I'm not in charge. We're just going to relax, enjoy and have a good time." Let me be the first to tell you that if you are hosting a wedding there is no way you are going to relax, enjoy or have a good time. For one thing the bride was two hours late, and for another, the caterers had been hired for a very specific amount of time. Which meant that they kept interrogating my mother, what should they do next? When should they start with the hors d'oeuvres? Should they serve the cake now? All of which drove Mom nuts.

    But in the end all went well, the ceremony was lovely and the catered dinner was really good; in fact, better than good (I've been living off leftovers all week). The best part for me was getting to spend the weekend with my mother, her sister (who came into town for the wedding) and their friends. You see, Mom and my aunt were born and raised in Tennessee. My mother met my dad at William and Mary (she was in college and he was in the Navy) and eventually they got married and moved to southern California, where my mother found herself marooned in Orange County in a 1960's suburb, raising three kids.

    In those days you met people playing bridge or if your kids went to the same school, which is how my mother knocked into two other women from the South. We will call them M and V. They are both from North Carolina originally, got married, moved to California, wound up meeting my mom in that very same suburb and they've been close friends for more than forty years. It was V's daughter who got married last weekend. The three of them have dealt with divorce, widowhood, illness, family dysfunction and God knows what else and have done all this with grace and humor. The whole clutch of us sat at one table during the reception, and one of M's sons referred to the three of them as "The Southern Mafia," which caused me to double over. He was right; you can call them Steel Magnolias, Southern Mafia or what you will, these are strong women who have kept families and traditions together in one of the most socially ephemeral parts of the US you can imagine. My sister and I still keep grits in the house (and we eat them!) Our families are still close. My mother and her friends still celebrate each other's birthdays and take trips together once a year or so.

    After the wedding my mother's friends stayed overnight and we celebrated with a big breakfast the next day (of course, grits were included). We reminisced, read the paper and drank way too much coffee. It was great.


    Wednesday, July 09, 2008
    Potato Soup

    This is a dish I was raised on from a child. You can eat it any time of year, but because the preparation is so easy it became a summer supper tradition in our family. This is potato soup at its most basic: onion, potatoes and water. (And salt and pepper.) My grandmother used to thicken it with a flour-water paste, but my mother quit doing that ages ago and it does not seem to make one whit of difference. No dairy is required: this is not vichyssoise. The soup has an earthen, potato-ey taste which is quite good. It does need quite a bit of salt, but potatoes generally do. Did I mention it's incredibly cheap to make?

    Proportions are as follows: chop one large onion to, maybe, four large potatoes. You can change this ratio based on what you have or what you prefer. Peel the potatoes, halve and slice them. Cover all of the above with water and cook on a low flame for a long time - more than an hour, at any rate. What you want is for the potatoes to go mushy and break down, thus thickening the soup with their starch. If the taters are holding their shape the soup isn't done yet. The onion will disappear, or nearly so, by the time the soup is done. Season generously with salt and fresh ground black pepper.

    Serve with fresh hot cornbread, preferably baked in a cast-iron skillet, and a platter of sliced tomatoes, green onions (a.k.a. scallions) and cucumber. Iced tea to drink. If you need to stretch this further serve a platter of deviled eggs as well:

    Hard-boil six eggs, cool, peel and slice in half. Sieve or mash the yolks and mix with a dash of white pepper, 1/4 to 1/2 tsp. salt, 1/4 tsp. paprika, one tsp. each of prepared mustard and white vinegar, and 2 tablespoons mayo. Stuff the mixture back into the egg halves and chill. Sprinkle paprika on top. These are, officially, the World's Best Deviled Eggs (and you can ask V., who is not a big fan of eggs generally but loves these).

    You can refrigerate leftover soup, but because of its heavy starch content it will resemble wallpaper paste when cold. Do not panic, just add a small amount of water and reheat slowly and it will be fine.


    Monday, July 07, 2008
    101 Yummy Ideas

    Mark Bittman, food blogger for the NY Times, has done it again. His latest "101 items" list is up here and this time it's 101 ideas for picnic food. If the site asks you to register (it probably will) and you don't want to, go to bugmenot.com to get some passwords for the New York Times website.

    Many of the commenters are begging Bittman to put together a cookbook of 101 lists; I'd buy it for sure. These ideas are versatile and could be used for a lot of other occasions besides picnics. Buffet meals, potlucks, side dishes... give the list a look and I'm sure it will give you some ideas.


    Saturday, July 05, 2008
    Talk to Me

    Talking to my patients about their lives and what they do is actually what I love most about my job in primary care; the time constraints I work under are the most frustrating thing about it. I've been fortunate to have some interesting conversations with patients lately. A couple days ago I was seeing a (rather anxious) patient with a lot of different complaints. I sifted through as many as I could and asked her to make a follow up appointment for this coming Friday for further discussion.

    "Well, I can't make it that day," she responded, looking a bit self-conscious. "I have my ukulele practice session that day."

    "Really?" Ukulele?

    "Yes." Before my eyes this woman began to brighten up, lighten up as she talked about her hobby. "I heard this recording of --" she named someone who's apparently pretty proficient at the instrument, but his name escapes me -- "and it just amazed me. There are so many styles of playing! I got my roommate interested, and it's just a lot of fun. I live in an apartment building and we can't have pets."

    "But you can have ukuleles," I finished. "I imagine there are a fair number of people around here who play. There's a significant Hawaiian population around here, especially in the South Bay."

    "Yes, but you can go on line - there are tutorials, and videos..."

    I stared at her. "I've been living under a rock, haven't I?" I asked.

    The conversation stayed with me for the rest of the day and I later shared it with V., who instantly broke into an imitation of Tiny Tim doing "Tiptoe Through the Tulips."