Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Wednesday, December 31, 2008
    Happy New Year

    Well. The office has been closed for a couple of hours, but I am still here, piddling, surfing the Net and taking phone calls. I'm on call tonight (I volunteered), which suits me fine - I've never been a big New Year's Eve fan. My favorite New Year's Eve memory is still from when I was seven or eight and went to a sleepover birthday party at the home of a classmate, whose birthday just happened to be December 31st. I remember their home clearly. My friend's parents were hip and young, or maybe they just seemed younger than my parents - they lived in one of the newer housing developments in my town, and their house had a wine cellar (a wine cellar! I'd never met anyone else who had one) and a sunken living room with a white shag rug. Every year they had an enormous tree, flocked white to match the rug, and it was the most glamorous thing I had ever seen. Bear in mind this was 1972 or so.

    At any rate, we brought our sleeping bags and bedded down in the glamorous living room next to that flocked tree. We stayed up all night, or close to it, and I was pretty grouchy the next day due to lack of sleep. My party favor, a scented candle shaped like a pine cone, graced our bathroom for years afterwards.

    It's odd to have such a clear memory of what was, after all, just a slumber party. None of my other New Year's Eves ever measured up to it, though; my second favorite Eve ever was several years ago and consisted of me at the computer with a bowl of M&M's while my parents went to the neighbors' boring party down the street. Tonight, I can tell, will not be a standout evening. I can hear the chants of Palestinian protesters from up the street while I fend off calls from neurotic patients (okay, they're not all neurotic, but I'm getting some real winners tonight). I didn't know the Israeli consulate was a block away from the office until this week, when the protesters started showing up.

    Still, things are not bad. My parents are healthy - in fact, my entire family is healthy - and this is a major blessing. I have a job; knock on wood, I will continue to have one. Tomorrow I will go to Pasadena with my parents and my aunt to see the Tournament of Roses Parade, and the forecast is for nice weather.

    Happy New Year to all the partyphobes out there, and remember, there's nothing like a bowl of M&Ms and the Internet on New Year's Eve. Unless you've been invited to a slumber party.


    Monday, December 22, 2008
    I've Been Tagged!

    Thanks to Dr. Mabuse, who tagged me with the following:

    1. Link to the person who tagged you.

    2. Post the rules on your blog.

    3. Write six random things about yourself.

    4. Tag six people at the end of your post and link to them.

    5. Let each person know they've been tagged and leave a comment on their blog.

    6. Let the tagger know when your entry is up.

    Hmmm, six random things. Here we go:

    1. I read cookbooks for fun, and I own way too many of them - easily over sixty.

    2. I'm a salt person - if you let me choose between potato chips and chocolate, I'd pick the potato chips every time.

    3. I'm way behind on movie watching; I saw Titanic for the first time two nights ago, and it's eleven years old! (Thanks, V. for hosting the movie night!)

    4. I celebrate Talk Like a Pirate Day every year. At work. It bolsters my reputation as an eccentric.

    5. I'm a huge fan of conductor Christian Zacharias and have flown to New York and Philadelphia to hear him. I think that makes me a groupie.

    6. If I find a character actor I like, I'll look up every film or TV show he or she has done on IMDb.com and then TiVo or rent them. Netflix is very helpful in this regard now that so many TV shows are on DVD.

    Six people to link to... hmm. I'll pick the Kitchen Hand, The Food Whore, The Pissed Kitty, The Head Nurse, Anne, and Shauny.


    A Holiday Activity Sure to Catch On

    Fruitcake shuffleboard.

    (Hat tip to Dave Barry)


    Tuesday, December 16, 2008

    The Rain in Spain Transcribes Mainly in the Plain

    My struggles with using this dictation system continue. Although it works well most of the time, occasionally either my diction or the program slips up and the progress notes that result are, shall we say, interesting. One might almost call them surreal. For instance, "carb loading" comes out as "car bloating." Earlier today I used the word "incessant" and the program helpfully transcribed "incest and" instead. That could have been a disaster; thank goodness I caught it before I signed the note.

    Sometimes you just have to take your humor where you can find it.


    Friday, December 12, 2008
    Merry Christmas! Please File my Advanced Care Directive

    It's that time of year again. The time of year that primary care doctors get a shower of cards and occasional gifts from nursing home corporations, orthopedists, neurosurgeons and hospital administrators.

    And patients.

    Some patients still bring in gifts and send me cards for the holidays, which I find quite heartwarming. It's nice to get the occasional expression of gratitude. I think this tradition has tapered off a bit in these days of managed care - I remember when my father used to bring box after box of See's Candy home from the office at Christmastime. Most of it was redistributed to friends and relatives, but given half a chance my sister and I would go through the boxes first picking out our favorites. I think perhaps the Starbucks Gift Card has replaced the box of candy as the standard gift, now that caffeine is more socially acceptable than sugar.

    I cherish the slightly off-the-wall gifts I have received in the past, such as the plastic doodad a physical therapy office once sent me. It had four arms all of which ended in knobs and turned out to be a back massager; my secretary demonstrated by grabbing it and running it over my upper back. Yeowch.

    The cards are nice, too. The ones from specialists often come with calendars (especially useful, they go into exam rooms to help me figure out the date when the patient's symptoms started or the date they're scheduled to go back to work). The most touching ones are those with shaky signatures from my elderly patients. Some are so isolated that I may be the only person in their lives to whom they send a card.

    But the funniest one this season has to be the card I got a few days ago, included with the patient's completed copy of an Advanced Healthcare Directive. The message inside? It became the title of this post.


    Wednesday, December 10, 2008
    Space Station Flyby

    Per L.A. Observed, the space station will be passing overhead tonight about 5:21 p.m. Here's a diagram:

    UPDATE. V. and I stood out on the balcony for ten minutes watching for the ISS to pass overhead. Never saw it.


    Tuesday, December 09, 2008

    We're deep into the madness of P4P (pay for performance) here, in case you're wondering why I haven't posted much lately. This basically means tracking down all patients who haven't had their diabetes checked/ gotten their pap smears/ had their colonoscopies/ etc. It is a huge amount of work; The Firm has a whole stable of employees who have been spending time doing nothing but referring patients to come in and get this stuff done. Why are we paying people to call patients all day?
    • We get paid to do it. Managed care insurance companies have a fund of incentive money they pay to groups (maybe to individual doctors as well? not sure) who meet their criteria. Of course they keep raising the bar, so it gets tougher every year. They also add new criteria every year - for instance, if you treat somebody with bronchitis with antibiotics now, that counts against you. (It isn't as crazy as it sounds; most bronchitis is viral and responds better to inhalers. But that's another post.)

    • The groups that do the best get good publicity. Every year the insurance companies publish their list of groups that provide the "best care." Of course this list gets lots of local publicity and winds up in the L.A. Times (for example) every year. This hopefully translates into more patients signing up with The Firm.

    I hate P4P season - we all do. Not that I'm arguing against giving people good care and getting their cholesterol down, mind you. It just seems that the goal is lost in a paper chase: The statistics count more than the patients. Also, we always have those stubborn few who won't take their cholesterol lowering meds, aren't compliant with their diabetes treatment or hate mammograms. Such patients are anathema to any good paperchasing doc. It's difficult to look at these people and not think You're ruining my numbers!, horrible as that sounds.

    I foresee a day when these patients will form a tribe of outcasts, wandering from group to group and primary care doctor to primary care doctor, staying just long enough for the "care provider" (as we will doubtless be known) to find out that Patient X doesn't do mammograms or statins and then being expelled to blot the escutcheon of some other hapless M.D. That's what happens when you do cookbook medicine and the book in question becomes more important than the patient.

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    Monday, December 08, 2008
    Comment of the Day

    From one of Ann Althouse's posts, about book clubs:

    Every new book club should start with Sartre's "No Exit".

    'Tis true: Hell is other people in book clubs. I belonged to one once, but quit due to several reasons: lack of time, dislike of the books chosen and the fact that one of the members viewed it as an opportunity to go on and on and on about herself. Not that she didn't lead an interesting life, but after the third session or so the monologue got to be a little draining.

    I learned that I never want to read another book by Gore Vidal (but I did manage to get my fellow members to read Laurie Colwin, a favorite author of mine).

    And, yep, I'm blogging again. Stay tuned.