“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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Lightsabers!

For a little humor today, I give you a collection of pictures with lightsabers photoshopped in. Great fun.

Labels: Pop Culture

posted by Dr. Alice at #

 
Saying Goodbye


It's the hardest thing in the world.

The process of dying being what it is, it's rare that you get a chance to sit and talk with someone knowing that this will be the last time. The Last Time. This is because dying patients are usually confused, narcotized or comatose and aren't aware enough to carry on a conversation. They don't teach this stuff in med school - well, that's not a fair statement. These days medical schools and residency programs do teach end of life care, or at least try to. But there is no way to explain what's going to happen when you go in the room to talk to a patient, someone you know, knowing that you will never meet again in this world. It's scary. It's puzzling (is it okay if I weep? Should I be professional?) and it can be incredibly rewarding. These are the conversations I remember, the moments that keep me practicing medicine.


I had one such conversation many years ago with the mother of a patient who had AIDS and was dying of progressive multifocal leukoencephalopathy (a particularly nasty and slow way to die). He was living in a long-term care facility where I was on staff and she had come to be with him; we worked together for months. Although the other doctors on staff were involved with his case I know that she felt the most comfortable with me. I had scheduled a vacation abroad with my mother months before, and as the weeks passed and the patient slipped into a near-comatose state it became clear to me that he was going to die while I was out of town. His mother had asked to meet with me the week before I left, and during our conference I said: "I need to tell you that I'm going out of town next week. I would cancel this if I could, but I made these plans months ago and I can't. So I wanted to tell you..." I paused... "that I won't be here."

She understood what I was saying and said thank you, and hugged me, and we cried. I told her how much I'd liked taking care of her son - and I had; he was a wonderful guy. When I returned from vacation the patient had in fact died and I never saw her again.


This weekend I met with a patient in her nineties who was diagnosed with cancer months ago. We gave her treatment for her symptoms and she improved for a while, but now she's been failing for a month or so. She bounced in and out of the hospital a few times and the hospitalist raised the issue of hospice care; she and her family agreed to stop treatment. She was transferred to a nursing home pending hospice arrangements and I went to see her there.

She took my hand and we sat on the side of her bed. "I'm so glad to see you!" she beamed. It was stunning to see the good spirits she was in. Denial was not an issue: she was completely aware of her prognosis and accepted the fact that she would not live much longer. Every time she comes to see me in the office she tells me that she loves me and she said it again today: "I love you, Doctor. You're the best doctor I ever had. My family's so glad you've been taking care of me. I've known you for what, now, fifteen years?"

"Close," I confirmed.

"Well the first time I saw you in the waiting room, I said to myself: 'That's my doctor.' And I was right."

We were sitting on one of three beds in a three-person room, curtained off from the other occupants. I stared out the window at the alley for a moment and thought what a strange place it was to have such a conversation bordering on eternity, then thought: well, what would be a better place? There is no appropriate place.

"Do you feel okay?" I asked her. "Are you in pain?"

"Not right now, but doctor, I been in some terrible pain. Some nights I used to ask the Lord to take me now. I don't want no more pain."

I reassured her and told her the hospice staff would set her up with medication: "All you have to do is ask for it." She had asked to go home rather than staying in the nursing home and I promised her I would make those arrangements. Then I took a deep breath and, fighting a lump in my throat, told her how much I had enjoyed being her doctor.

"I love you," she repeated.

I hugged her. "I love you too."

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Sentence You Don't Want to Read


When the radiologist who did the biopsy forwards you the path report you don't want his email to read simply "Hi, she needs an oncologist."

The sentence you don't want to say to the patient: "The biopsy did show cancer."

It's especially hard to get those words out when you hear a happy infant burbling in the background.

Labels: Medicine

posted by Dr. Alice at #

 
Evil Doctor Conversations

Tonight in my usual evening telephone chat with V. I began reading to her from the Phobia List, which I had just discovered online. As with so much medical esoterica, one could probably spend hours just reading through this list. The sheer entertainment value of phobias is incredible.

"Lachanophobia," I read aloud."Fear of vegetables. That's probaby why I don't like going to nursing homes."

We both dissolved into laughter.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
My Take on Healthcare Reform


You knew it was coming.

I don't really have the time or, at this point, the functioning thought processes to give you a heavily-researched, well-worded essay on the pros and cons of government health care. I'll just give you a few points that have occurred to me as a primary care physician. When it comes, and I have no doubt it will, a government funded health care program will fail unless a few points are straightened out first.


Before such a program is implemented we need more primary care doctors. There is a huge shortage of primary care providers in this country. There are a lot of reasons for that; compared to the specialties primary care is poorly reimbursed and involves much longer hours. We also get most of the scutwork - jury duty excuses, disability paperwork and Pay for Performance. This last issue is huge, but that's something for another post. The reason I say we need more docs in primary care is that in order for a huge unwieldy national program to work it has to be implemented at ground level. We are ground level.

Medicare has a big problem, and that problem is that no one doctor is in charge of the patient. In other words, it isn't uncommon for me to see patients who float from doctor to doctor, go off to see specialists, get tests and get their meds changed, and then turn up on my doorstep completely unable to tell me what type of test they had done or what the specialist's take on it was. Now, many times the patient does have a PMD, who does call the shots and is aware of everything, and that's great. But too often that is not the case. Before instituting a national plan I think the federal government should run Medicare more like an HMO, in that every patient needs to get a PMD to coordinate workups and testing.

Another problem with Medicare is that the government is slashing reimbursements to doctors and has been doing so for years. This means that a lot of doctors are now no longer accepting Medicare. These patients either need to pay cash, have a fallback private insurance plan or find a doctor or clinic who will agree to see them. This problem is not going away any time soon, and no proposal of which I am aware has addressed this issue, either.


Another issue is that there has to be tort reform. That could mean malpractice capping, or it might mean mandated arbitration. Did you ever wonder how Kaiser keeps its rates so low, or how the VA program holds its costs down? The answer, my friend, is arbitration. Before suing you must go through meetings in which both sides try to reach a compromise. I'm not claiming it's perfect or the best way to go, but I am saying that in order for the President to even come close to meeting his wild claim that a national health program wouldn't cost the country any additional money, something has to be done about runaway malpractice rates.


People will need to get used to waiting and being told "no." There's going to have to be a huge cultural change in the U.S. before the public will be happy with national health care. What do I mean by that? I'll give you a few examples. I have a British friend who lives in Brighton, but grew up in Nottingham. When she first moved to Brighton she couldn't find a doctor to take her, as all the medical practices were full. Yes, full. For over a year, if she needed to see the doctor, she had to travel to her MD in Nottingham. In case you are wondering, the two cities are 150 miles apart. She told me this story as though it were nothing unusual, and I'm sure it wasn't. The big, dirty secret about nationalized health coverage is this: just because you have insurance, it doesn't mean you'll get a doctor. As I said above, if there aren't enough docs to go around, the situation hasn't improved. Also, I accompanied her to her doctor's office the day she had an appointment for a Pap. Five minutes later she was back in the waiting room. You aren't going to have a chance to spend time with your doctor or to get many questions answered, if this is anything to go by.

"But what about physicians' assistants or nurse practitioners?" you might ask. "Can't they handle basic health care?" Yes, they can; but NPs and PAs are nobody's fools, either. Most of them get specialty jobs too. They work with plastic surgeons or orthopedic surgeons, or in outpatient oncology programs (most of my aunt's care is coming from NPs and PAs right now; she sees an MD only once a week). That means you're still SOL when it comes to finding a primary care provider, MD or otherwise.


Let's talk about wait lists for other stuff. Mammograms, for instance. The reimbursement for mammograms is minimal and it comes with a high malpractice risk. This means there's a shortage of radiologists who are willing to read them and there's a shortage of facilities providing them. When every woman in America over the age of 40 gets insurance and runs to the phone to schedule a mammogram, what do you think is going to happen? You got it. Say hello to six month waits for mammograms.


None of this is to say that people shouldn't have access to insurance, or that coverage should be predicated on their having a job. It shouldn't. And insurance companies should not be allowed to deny policy coverage to someone with diabetes or other chronic illness who's trying to buy a plan. I don't have a suggestion for a workable national insurance plan, though I wish I did. I'm just pointing out that it isn't going to be all rainbows and unicorns once everyone has insurance.

Labels: Medicine, Politics

posted by Dr. Alice at #

 
Thank You, I've Been Screened


Every day after taking the shuttle and checking in at the medical center, we patients and caregivers are given a sticker to wear. What do the stickers say? It's the title of this post. The stickers are distributed to us after we have filled out forms stating that we are not coughing, do not have a runny nose or a fever, and so on. Bottles of hand sanitizer are everywhere.

No, I am not the Boy in the Plastic Bubble, but I am pretty damn close. I am currently acting as caregiver for a relative who's undergoing outpatient treatment at the Seattle Cancer Care Alliance. She's not in the hospital and I am doing my best to keep her that way. The best way to do that is to observe the many, many precautions on the handouts which the hospital distributes at every possible opportunity. Food hygiene, home hygiene... nuking sponges in the microwave to kill bacteria, avoiding whole grain breads and crackers, scrubbing bananas before you peel them. It never ends. I actually turned this experience to some good use by writing another guest post for the Home Ec 101 website, which you can read here if you are so inclined.

Spraying Clorox and wiping things down is a lot of work but worth it. It has given me a new appreciation for the marvels of our immune system, for one thing, and I now have some new ideas for my patients who are plagued with MRSA infections. MRSA is a nasty bug and can affect anyone... you don't have to be immunosuppressed to get it. We are washing sheets and towels twice weekly, using a lot of hand sanitizer, using paper towels and napkins (cloth being a bad idea for someone who is immunosuppressed... it can harbor germs) and so forth. Earlier this week my relative's white blood cell count plunged from 10K to 2K, then to 1K, so I am keeping an eye on her. Today it will be lower still but we are hoping that her count will bottom out over the weekend and then start to return.

In a frenzy of planning for this visit I packed my otoscope/ophthalmoscope kit, a box of rubber gloves, a stethoscope and my portable blood pressure kit. So far none of them has been needed. Her treatment has been relatively uneventful so far and I hope it stays that way. I'll post more updates later.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Must See Site

Go take a look at these incredible, one-hundred-year-old, color photographs of Russia. Yes, color. They're absolutely stunning.

(h/t to Jo of Head Nurse)

Labels: Pop Culture

posted by Dr. Alice at #

 
Random Bits of Info



Voice dictation update: "fenofibrate" comes out as "phenol fibroid."

Today V. and I learned that the ophiasis pattern of hair loss means "a bandlike pattern of hair loss encircling the head, resembling the laurel leaf crowns of the Greeks." This information came to us courtesy of Derm.

Subway is not a half bad place to go for lunch. A Subway store opened just down the street from us and it's always packed at noon. As I wait in line I see many customers wearing scrubs; this place is getting a lot of business from the staff of doctors' offices nearby.

Oh, and I got a gig as guest poster at Home Ec 101. Go take a look.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Not an Option, Evidently

Had a conversation today with a patient who is adamant about wanting non-hormonal birth control. I referred her for the IUD, but it is not covered by her insurance.

"What are my other options?"

"You're looking at barrier birth control. That would be the diaphragm or condoms."

"Yuck."

"Well, there's celibacy."

"Oh, you're funny."

And that was the end of that.

Labels: Medicine

posted by Dr. Alice at #

 
Beware Cartoonists Bearing Gifts

You may have heard of Stephan Pastis, the cartoonist who draws Pearls Before Swine. I think it's one of the best comic strips currently published, and one of my favorite aspects of the strip is his ability to parody other comics. Most recently Pastis brought Mary Worth onto PBS as a guest (she stood stock still for four panels and said nothing, alluding to the glacial pace of the strip). He's also thrown a few zingers at Sally Forth and others, but he's saved his best jabs for Family Circus.

Back in July there was a big comics convention in San Diego, and Pastis attended. The night before he was to speak on a panel he was in a bar having a quick drink when he ran into Jeff Keane, one of the authors of Family Circus. Pastis got a brilliant idea:

“Hey Jeff, you have to come to my panel tomorrow,” I told him.

“Why?” he asked.

“Because every time I do a panel, someone inevitably asks me what other cartoonists think when I parody their strips.”‘

“So?” he said.

“So if somebody asks that question, I can surprise everyone by introducing you and showing them that we know each other and are actually good friends.”

Keane agreed to come.

What happened the next day? Well, you'll just have to click to read it...

Labels: Comix

posted by Dr. Alice at #

 
A Rare Restaurant Endorsement


"Okay," my cousin demanded a few weeks ago, "'fess up. Who went to 'Wise Guys'?"

"It was me," I humbly admitted, raising my hand.

We were standing in my aunt's kitchen in western Pennsylvania. Earlier that day my parents and I had been driving to Aunt D.'s house from the Pittsburgh airport, and things had been a bit tense. We had left at crack of dawn from Stratford, Ontario, and had gone through customs at six a.m. without breakfast. Plus my dad had displayed his classic stubborn argumentative self at the Pittsburgh rent-a-car counter and I had come very close to braining him with my suitcase.

I won the "honors" of driving from the airport to my aunt's house and we were all starving. Dad had let it be known that he would be very happy to stop any old time for a bite. So when a certain red-and-white sign had caught my eye from the road, I shrieked "We've got to stop here!" and promptly pulled in.

The sign read: Five Guys Burgers and Fries. Had it not been for a chance conversation a few weeks before this would have meant nothing to me. In fact the conversation was so random that I still cannot remember who my conversational partner was (a patient? a drug rep? not sure). Nevertheless the name of the business stuck in my head, and since I was driving, the decision was easy. Into the parking lot we went.

This chain (it is a chain) is awesome and reinforces my adage that there is no restaurant recommendation like a personal recommendation. The unknown person who clued me into Five Guys swore up and down that it was the best burger they had ever had. All I can add is, YUM. First point: they have free roasted peanuts in the shell. The peanut presence totally escaped me but it did not escape Dad, who had a little cardboard box of the luscious legumes loaded up before I had finished ordering for the three of us. Second extremely important point: you have carte blanche to order your burger as you like it. Which is to say, you make your choice of multiple condiments, relish, onions, tomato, lettuce... etc. (Sorry, Australians, no beetroot available.) If you study the menu you'll see what I mean. My mother changed her toppings order three times and I felt sorry for the poor fellow at the register, but he handled the situation with aplomb.

Third point: portions are HUGE. I mean, a "regular" burger order is a double. A "small" has a single patty. French fry orders are fresh, delicious and HUGE. I ordered a large standard fries and a regular Cajun fries for three of us and there were way too many fries, probably enough for five or six people. I kept apologizing to my folks for over-ordering and trying to explain that all I really knew when we arrived was the name of the place. I don't think there are any Five Guys in California, at least not that I know of. And fourth and final point: everything, everything, is cooked to order. They also have hot dogs, which I bet are delicious, but we wanted nothing but the burgers. We agreed that the regular fries are better than the Cajun (way too salty).

Five Guys are also very fast. We hit the place in the middle of the lunch crowd, but I just had time to get sodas and paper cups of ketchup for the three of us before our order was called. After we finished I studied some of the rave reviews posted on the walls and deduced that "Five Guys" was started in the Virginia/Washington D.C. area about 1996 and has since then expanded up and down the Eastern seaboard. Given that there are three such restaurants within an hour or so of my aunt's place I have to believe that they are doing pretty well. For those of you who know western PA, there is one on Rte. 22, one on Rte. 30 and one in Johnstown.

My cousin confessed that she can never remember the name "Five Guys" and always calls it "Wise Guys." Whatever you call it it's a darn good burgers-and-fries place and I would highly recommend it.

Our collective mood improved greatly after our visit. As we piled back into the car on that humid afternoon my father announced, "You know, even King Tut didn't have air conditioning. Or a car."

"He didn't have Five Guys either," I retorted, backing out of the parking lot and back onto Rte. 30.

Labels: Ingestion

posted by Dr. Alice at #

 
Team Bonding! Or, We're Totally in Dilbert Territory Now

I have great admiration for my boss in many ways. He has overseen The Firm from its small beginning with just a few doctors to its current status as one of the largest medical groups in L.A. His schmoozing skills are unparalleled - make no mistake, this is a major asset and one I wish I possessed. And he believes in the value of corporate culture, which has kept us together and going strong for lo these many years.

Having said that, he's come up with some mighty hairbrained ideas in his time and he has just emailed us the latest of such. He wants us all to do Myers-Briggs personality testing prior to the next corporate retreat.

Yes. Personality testing. I can see where this might be relevant if he were dealing with a group of managers, but I don't really see the point when applied to physicians. Granted, diplomacy and tact are relevant when it comes to running a practice but doctors are trained to treat patients, not to herd cats. When it comes to running a practice you find the rhythm that works for you and stick to it. I'd say also, at least in our group, that the physicians who don't like how we do things self-select and leave. That doesn't mean they aren't good doctors or that we had horrible disagreements; it just means the group practice model didn't work for them. And I admire them for realizing this and striking out on their own.

I guess what I'm really asking is, what is this supposed to accomplish? And my answer is not a lot. The docs who are talented holy terrors (and we have a few) already know this. Those of us who are eclectic (not to say eccentric) already know that. No matter what my Myers-Briggs results show, I don't see that they would change my practice style any... I've been doing this for sixteen years.

V. sent me a succinct email after we got the news: "OMG!!!" I responded as follows:

I seem to recall during our mandated pain management training that there was a chapter on Myers-Briggs which included the results for serial killers like Ted Bundy. I think I may go look up those results and copy them onto my test… ought to be good for a laugh.

It's a delicious thought, but I want to keep my job. I thought better of it.

Labels: Medicine, Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
This Pretty Much Says It All

Labels: Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
Birth Control: an Underused Option

Via Not Martha I found this link to an excellent article about IUDs. I agree with the writer: I can't understand why more women don't use them. You do have to pay up front if your insurance does not cover the device, and this can cost from $300 to $500; but they are good for up to ten years. Even if you only used it for five years that would come to less than ten dollars per month, cheaper than the pill. I always offer it as an option, especially if the patient is looking for a birth control method which does not involve hormones.

Labels: Medicine

posted by Dr. Alice at #

 
Tech Support? Hello?

Well. It's been brought home to me once again that when it comes to technology you can file me in the "epic fail" category. For months I've been struggling with an extremely slow computer line and have done nothing about it - mainly because I didn't know where to start. This afternoon, having a recent phone bill handy as a reference, I finally called the 800 number for Verizon and was directed to their website. It ran a program, checked the speed of the line and reported that yes, I did indeed have a speed problem. I clicked around some more and finally found a FAQ which suggested turning off the modem, waiting fifteen seconds and plugging it back in again.

It worked.

I can't believe it was that simple. I really can't believe I waited months to do something about this. At any rate, at least there's a happy ending.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
How To Celebrate a 50th?

I always enjoy reading Mark Bittman's food blog, Bitten. Over the last several months he's accumulated a few guest posters whose writing and recipe ideas are also excellent. A recent post by Daniel Meyer, dealing with his efforts to create a nice fiftieth birthday dinner for his mother-in-law, contained a suggestion that made me laugh out loud:

My first thought was to buy her a quart of ice cream, a bottle of whiskey and a box of Kleenex, but that seemed insufficiently celebratory.

I have not yet reached this milestone, but several of my friends and colleagues have. Perhaps when it's my turn I will mark the occasion in this manner. We shall see.

Labels: Ingestion

posted by Dr. Alice at #

 
Bons Mots

1. Last week I was examining an older patient. When I tested the range of motion in his knee I noted some crackling and noted that he had "crepitus" in the knee.

"Why do you call it that?" he fired back. "Does that mean I'm decrepit?"


2. Reviewing notes from urgent care today, I saw that the medical assistant had listed the patient's chief complaint as a "staff infection." She had a boil which was likely staph, all right, but I could not help thinking that an infection of the entire office staff would indeed be something to complain about.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
101 Ways to Get Your Veggies

Hooray: NY Times food writer Mark Bittman has come out with another 101 list, this time of 101 salads for summer. I've only glanced at it so far but it looks delicious. Bittman also recently published a collection of many of these lightning-fast recipe ideas as Kitchen Express, a fun read and a great source of ideas for cooking last-minute meals.

Labels: Ingestion

posted by Dr. Alice at #

 
Julius Shulman



A well-known Los Angeles photographer, he died July 15 at the age of 98. This is perhaps his best-known picture, a case study of a house in the Hollywood Hills. Architecture was his specialty.

Labels: Los Angeles, Pop Culture

posted by Dr. Alice at #

 
On Dramatic Structure


This weekend I saw the L.A. Theatreworks production of The Physicists by Friedrich Durrenmatt. If you live in Los Angeles and have never seen one of their productions, I highly recommend them. These plays are recorded for radio rather than being performed conventionally and are broadcast on NPR. Theatreworks also sells recordings of the plays, which are great to listen to while you're driving. During performances the audience sees the sound effects engineer create the sounds of doors opening, wine being poured into a glass and so on. The actors sit and wait until it's time for their characters to speak, at which point they come forward to the microphones and read from their scripts (being careful not to rustle the pages!) There are no sets or costumes as such, although the actors may choose to dress in a style reminiscent of their characters if they choose. At this weekend's performance some did and some did not.

The Physicists is a message play, the message in question being that Nuclear Weapons are Bad. It was first performed in 1961 and was written in German - our production was a translation, of course. It's a comedy-drama with an absurdist tinge to it and I found it a pretty typical example of this sort of thing. It was really the actors (Bruce Davison, John De Lancie and Gregory Itzin) who made the performance enjoyable. Their acting and the sound effects in the background combine to make the set almost coalesce in front of your eyes: it's amazing. It's such a pleasure to watch gifted character actors doing their thing. I find they're usually much better than A-list "movie star" actors, who seem to make careers out of playing the same basic character over and over again.

These message plays, though, all seem to have the same basic structure. They open with the whimsical, slightly absurdist setting and the audience getting to know the characters. Plot twist at end of first act! Second act opens with the ramifications of the plot twist. The characters' reactions segue into the Twenty Minute Lecture, as I call it, where the action comes to a grinding halt so that the playwright can air his thoughts and opinions and the audience just has to sit there and take it. Then the characters pick up their roles again and the play comes to some sort of resolution which may be hopeful, depressing or indefinite. A really classic example of this sort of play would be An Inspector Calls, which masquerades as a murder investigation but is really an anticapitalist polemic. I enjoyed it, but after the first ten minutes you know exactly where it's going to go.

This sort of play bugs me, but it isn't the message that is the problem. Good theater should challenge its audience, after all. It's the Twenty Minute Lecture that I dread: it ruins the flow of the play. I think the only playwright capable of getting away with this sort of thing is George Bernard Shaw and it's because his characterization and dialogue are so good. When his characters debate you believe they're having a debate, not that the playwright is arguing with the audience. Durrenmatt's characters are good enough at the beginning but turn into straw men, only there to expound on their creator's theories.

One could argue that blogs are guilty of this same crime, but I think most people read blogs specifically to get the writer's take on things. Besides, if the reader finds the post boring he or she can always click on to something else... now wait just a minute. Get your hand off the computer mouse! I'm not done ye

Labels: Los Angeles, Politics, Pop Culture, Science

posted by Dr. Alice at #

 

Not Tonight, Dear...

Recently I got an email from a patient noting that he had been getting really severe headaches during sexual intercourse. Naturally, he was concerned about this and was wondering what might be causing it. This is a well known phenomenon in neurology sometimes called benign explosive sexual headache. It's more common in men than in women. I can state that I have seen several patients who had this problem and they all were male. (This is called anecdotal evidence.)

Most episodes of this type of headache are, as the name suggests, benign and can be controlled with medication. It seems to be more common in people with a prior history of migraine. In a few cases it can be an early sign of brain aneurysm but this really is not common; when I see someone with this complaint it is not my first impulse to get a brain MRI. It's a good idea to get a family history of aneurysm or polycystic kidney disease, though.

If medication is required, your best bet is a beta blocker. (Which, in its turn, may induce erectile dysfunction, but we can't have everything.) Another option would be taking a pain medication, such as ibuprofen, before intercourse. Once the headache starts, taking meds doesn't seem to do much good. You just have to wait for the headache to wear off.

Labels: Medicine

posted by Dr. Alice at #

 
Glorious Fourth



As to what I did for the holiday weekend: Not all that much. Went out to the suburbs to visit my folks; swam; priced refrigerators at Sears (Really. I need a new one. My current fridge is maybe 20 years old and is on its last legs); saw Transformers II; and bought an iPhone.

Yee-haa! I have an iPhone! I'm still in the process of programming it, but I have one.

As regards the Transformers movie, it was remarkably bad. What can you say about a movie that uses a dog-humping joke three times (once with a robot)? I can't say it was worse than any other big, dumb summer movie I've seen in the past... Independence Day and The Day After Tomorrow come to mind. Mainly I went because part of it was filmed on location at my alma mater and because I'm a fan of a couple of character actors who were featured in it - John Turturro and Glenn Morshower. This sort of film always has to have a couple of competent actors to anchor it. It also had a lot of neat location shots of Egypt and Petra, Jordan. Having been there six months ago, the travelogue bit held my attention.

Other than that, not much happened and that suited me fine. Just having three days off in a row was enough.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Best Excuse Ever

For the most part we docs are reluctant to prescribe antibiotics without seeing patients. The ever-present specter of drug resistance plays a large part here, not to mention the low (but possible) risk of side effects associated with antibiotic use such as allergic reactions, antibiotic-associated colitis and yeast infections. Sometimes, though, we don't have a choice. Such situations usually arise when we're on call and have no choice but to assess symptoms over the phone; after all, you can't send people to the emergency room for everything. In these cases you take a history over the phone and do the best you can.

The most unusual case for antibiotics that I have ever heard was fairly recent, a patient calling on a Friday night with symptoms of a respiratory infection and a history of recurrent sinusitis. After sharing all this he added: "I'm going to swim with the beluga whales tomorrow for my birthday and I know I'm going to get worse after being in the water. And it's too late to cancel our reservation, we'll still have to pay for it."

My mouth fell open. "You're going to what? With what?"

"Swim. With belugas." He sounded entirely rational, but to me this made as much sense as saying "We're going to fly with pink elephants tomorrow." Apparently it's possible to make reservations at Sea World, or some such place, to swim with beluga whales.

I gave him the antibiotics. Even if the guy were lying through his teeth I felt he deserved points for originality.

Labels: Los Angeles, Medicine

posted by Dr. Alice at #

 
Overdue Update



I've been feeling bad for a while now that I have not posted more on this blog. But pretty much all I have to talk about is work, and I don't want to be posting about other people's (which is to say patients') travails. It's bad form to reveal someone else's personal tragedies. Listing is one thing, details another.

Though I haven't written about it, much has been happening here in Feet First Land and not all of it good. Back at the start of the year I went on a lovely trip which I still intend to post about more someday... but I returned to several other changes: my two former office partners have left -- one moved to NYC, one moved just down the hall -- and I now have two new partners. I will refer to one of these two new partners as The Thorn In My Side, or TTIMS, because that's what he is. TTIMS is, at a rough guess, 35 years older than I am. He's a nice enough fellow but he seems to have graduated from a residency program circa 1912. Lest you think I am exaggerating, I will tell you that he calls all female MD's he works with "honey" and "babe" and squeezes their arms -- not meaning to be creepy but affectionate. I can deal with that (just), but there's more. He also micromanages (in the sense of holding a magnifying glass over his secretary) his office, but apparently to little effect: He sees about half the number of patients that I do. The biggest problem is that he perpetually complains but refuses to change anything about his office arrangements. My motto has always been "Don't complain unless you're willing to take action," but this is exactly what he won't do.

In addition, and more saddening, is the almost endless parade of bad news among my patients. A new patient with mental status changes turned out to have a glioblastoma (brain tumor) and died within a month. I've had several new diagnoses of lung cancer, brain cancer, myeloma and a probable amyotrophic lateral sclerosis. And a beloved relative has been diagnosed with a serious illness, is now undergoing chemo and will need further aggressive treatment later this summer (I have been signed up as caregiver when relative begins this treatment). In short it's been a difficult six months.

The good news: I think I have finally found the impetus to begin the novel about primary care medicine that I've always wanted to write. Who knows if anything will come of it.

Labels: Medicine

posted by Dr. Alice at #

 
Man In the Mirror


I'm always going to wonder what Michael Jackson was thinking about when he sang these words:

I'm looking at the man in the mirror
I'm asking him to change his ways...
And no message could've been any clearer
If you wanna make the world a better place
Take a look at yourself and make that change

I had a chat with one of our pediatricians this afternoon after the news broke. We agreed that children everywhere could probably sleep better now. Sadly, the man had talent to burn and he was one of the world's great dancers; he was also completely screwed up.

He also left us a legacy of whacked-out wedding videos... we will be watching wedding parties reenact "Thriller" for a long time.

Labels: Los Angeles, Pop Culture

posted by Dr. Alice at #

 
Pixar Aims High, Doesn't Miss


I saw Up this weekend, which means I've already seen two more films this summer than I saw last year. Here's your real short film review: it's excellent. Go see it.

Long version: last week after seeing Star Trek my friends and I went to dinner, during which I whined: "What is it about screenwriting today? Why doesn't anybody realize it's about the characters, and the dialogue, and the plot? I mean, look at those trailers we watched!" (G.I. Joe and Transformers II, in case I have to remind you).

One of my friends who has a fair amount of screenwriting experience responded with reasonable answers (the amount of money invested in films today, the value of toy rights, video game rights, etc.) I know he's right, but in all but the most exceptional case you wind up with crappy, unwatchable films with the sound of things blowin' up for two hours. Oh, and perhaps the hero and heroine getting it on for a couple minutes, just for a change.

Pixar has miraculously managed to avoid this pitfall. They consistently come up with brilliant, imaginative, watchable films featuring characters that the audience identifies with. Up is no exception; in fact I would say that Pixar has outdone themselves with this film. From reading reviews on IMDb I got the impression that the people who had issues with Up thought it was either a) too sad or b) had too much comic relief. Me, I thought they hit just the right balance.

Let me be honest and say that you probably don't want to take a little kid to this film. It deals with the Big Scary Stuff like aging, death and having your parent desert you. But Up touches lightly on these heavy themes and gives us a healthy dose of imagination and adventure to sweeten the bitter undertone, and sends you out of the theater feeling uplifted. So to speak.

I will just give you a few of the highlights that struck me. The montage at the beginning of the film, which tells the audience about Carl (the protagonist's) life, is brilliant and will in fact move you to tears. What really hit me was a split second shot during the wedding scene. The camera viewpoint moves from the bride's family, madly applauding and happy, to the groom's family - tightly smiling and tepid. That's all we need to know about why child Carl is so monosyllabic and why he is the way he is as a senior citizen. Brilliant.

The dogs: some of the commenters in IMDb felt they were crappy comic relief. I couldn't disagree more. They don't literally "talk," but wear translator collars which turn their thoughts into English. This was another incredibly imaginative idea, as it allows for lots of humor when the collars malfunction (Alpha Dog's collar keeps doing this) and gives the dogs an interesting cadence in their speech. It's slightly stilted and the syntax is a bit off - in short, they don't sound like people, they sound like dogs. Also, I give the film major points for avoiding butt-sniffing jokes, "dogs marking their territory" jokes and so forth. They don't have to go there: they're Pixar.

Ed Asner does great voice work as Carl Fredricksen, and it's a delight to hear Christopher Plummer as bad guy Charles Muntz (his character resembles Errol Flynn crossed with Charles Lindbergh). His character's name is a bit of an inside joke, as Walt Disney's original backer was named Charles Mintz. He later co-opted the rights to Disney's first hit character, Oswald the Rabbit. Disney responded, of course, by coming up with Mickey Mouse.

Long story short, this is probably the best movie of the summer. It'll make you laugh, it'll make you cry, it'll make you think (but not too hard). It has travel, adventure, life, death and talking dogs. Go see it.

Labels: Pop Culture

posted by Dr. Alice at #

 
Get Your Trek On

Star Trek premiered on first-run TV when I was just a tad, and though I have a few memories of the show in its original run I never really watched it until I went to college. My freshman dorm had a lounge with a television -- what, have your own television in your room? That's crazy talk! -- and the local TV station showed reruns of Star Trek every night at 10:30 pm. (In those days it wasn't referred to as TOS, since there were no other shows from which to distinguish it.) I forget now what drew me down there in the first place, since I never had really watched the show, but I know what kept me coming back: the sense of community. The audience was mostly guys who had watched the show so many times that they could tell you from the opening shot of the Enterprise circling a planet which show it was. In fact, they would compete to see who could shout out the name of the episode first.

I still have happy memories of those evenings in the lounge. For one thing, even though the gender makeup of the audience was about 80 male/ 20 female, there was no misogyny, no sense of anyone hitting on anyone. People were there to share their love for the show, and that was it. All attendees were welcome. For another, the fans' affection for ST was not blind hero worship but rather ironic. I was introduced to all the tropes of the show early on (i.e., Captain Kirk sleeps with alien girl and converts her to the cause of the Federation). My favorite moment may have been the bit when the crew was hiking up a mountain and somebody yelled "Dammit Jim, I'm a doctor, not an escalator!" After an evening of panicked studying, it was a refreshing break.

Years later when I was in medical school along came Star Trek: The Next Generation. You may not remember how eagerly this show was awaited at the time: Trust me, I sat in a lecture hall with Trekkies every freakin' day and I can tell you it was a hot topic. It was pretty good, actually, though the earnest PC premise of the show wore thin after a while. My real issue with it was the persistent theme that everything, everything, would be solved in the future. I'll give you an example. In one episode Captain Picard is complaining of a headache, and what's her name the Betazoid empath replies earnestly, "Something must be wrong. No one in the twenty-fourth century has headaches any more." I'll tell you what my response to that was: BULLSHIT.

Fast forward to residency. Deep Space Nine premieres. I'll tell you, as far as I am concerned this was the best Trek show ever. It had character development, conflict, drama, and the show wasn't afraid to develop plot arcs that took more than one season to resolve. This is almost unheard of in television even today; fifteen years ago it was an absolutely revolutionary idea. It also had Garak, the tailor/spy/refugee from Cardassia, and the most morally ambiguous character since Captain Renault in Casablanca. Oh, and did I mention the brilliant writing? Okay then.

I am finally getting to my point, which would be the recent Star Trek movie. I had not intended to see it, assuming it would be terrible, till I read a couple of glowing reviews online. Last night a couple of friends (who had already seen it once) invited me along, swearing I would love it.

They were right. It really is that good. It's true to the spirit of the show and the writers get the essence of the characters, but it doesn't take itself so seriously that it adheres fiercely to every bit of the backstory. And there's a good reason for this which is worked into the plot very nicely. The words "alternate reality" may make you cringe, but in this case they shouldn't - it works. What I really liked, in fact, is that "alternate reality" is usually just a toy for the writer to play with, but in this case you see the implications (very serious implications: the loss of a parent) play out. These implications are a bonding point for Kirk and Spock, who can't stand each other to start with.

All the characters get their moment in the sun. McCoy is a hoot, Scotty is a joy, Uhura is hot and smart. She and Spock appear to be getting along quite well by the end of the film, and I can't wait to see what happens with them next. If you're looking for small nods to the audience, the film has them: Kirk's commanding officer is Christopher Pike, and at the end of the movie he shows up in a wheelchair - you have to have seen a particular episode of TOS to get this. When we first see Scotty he's got a pet Tribble in a cage. And so forth.

Suffice to say my expectations were low, mainly because I have a deep distrust of movies that rely on special effects rather than character development (we had to sit through trailers for G.I. Joe and Transformers II, which are exactly the sort of dreck I am talking about). Star Trek does not make that mistake. You don't have to be a raging, con-attending Trekkie to enjoy this movie; despite my comments above, I don't fall into that demographic. Go and enjoy.
posted by Dr. Alice at #

 
Minty Fresh Oxygen



For nearly a week I've been down with some sort of horrible respiratory problem. I started with a persistent cough and then, gradually, a fist closed around my lungs and I started wheezing as well. Not wanting to take off work I resorted to raiding the sample closet and treated myself with an albuterol inhaler and cough medicine. I left work early on Friday, thinking that a day or two of rest would help, but it got worse. Saturday night I nearly went to the emergency room because every few minutes I'd have to pop upright to catch my breath. I have no history of asthma, by the way.

Sunday morning I decided to visit the after hours clinic run by The Firm and one of the docs there checked me out. I was wheezing badly enough that he offered me oral steroids - which I declined - but did give me a steroid inhaler and antibiotics, and told me sternly not to show up for work today. I followed his advice. I felt better a few hours after starting the new meds and am a lot better today.

Possible interesting side note: as an experiment this morning, I decided to try drinking coffee (an old home remedy for asthma; the caffeine has an effect similar to theophylline). I hadn't had any coffee for two days, as I usually lose my taste for it when I get sick. All I can say is, IT WORKS. I noticed the difference in my breathing by the time I had finished my first cup. I did develop some shakiness, probably due to the caffeine-albuterol combo, but I didn't care. All I could think was "Oxygen! Minty fresh oxygen!"

As I said above, I have no history of asthma, but I did have an infection similar to this about eight years ago. This one was worse. I really can't explain the wheezing or bronchospasm (I don't smoke, either). I do have a lot of empathy for people with chronic respiratory problems: this was no fun at all. Hopefully it won't come back any time soon.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
What's Your NPR Name?

I'm Alrice Troncones. Go here to figure out what yours is, then post in comments.

Labels: Pop Culture

posted by Dr. Alice at #

 
The Noble Art of Medicine

...and here we are at the ACP meeting. V. and I are roommates this time around and are sharing my computer (she brought hers but can't seem to get the wireless access to work). Philadelphia is beautiful at this time of year, though the budding trees are giving her allergies.

The national meeting of any medical specialty is always fun, giving MD's a chance to catch up with old friends from residency and/or medical school and two or three days of luxurious learning without having to worry about patients and phone calls. So far today I have attended lectures on insomnia, dementia, neurologic examinations and pain management. Tomorrow will include wound care and renal disease. This may sound dreary, but it's not; the speakers here are the best in their fields. You don't get an invitation to speak at a national meeting unless you're really good.

I haven't been to the sponsors' hall yet (drug companies, medical data management companies, locum tenens companies and so forth) but V. has. She came back with all sorts of goodies: a T shirt, travel coffee mugs, pencils, a flashlight and hand disinfectant. I plan to go there tomorrow and see what I can get.

I ran into one of my old cardiology professors from med school. He remembered me, and I was greatly flattered. Also, I took V. for a cheesesteak today and we toured the Reading Terminal Market, which she greatly enjoyed. We're both beat due to jet lag but it's going to be another early day tomorrow - lectures start at 7 am.

Labels: Medicine, The Doctor's Life, Travel

posted by Dr. Alice at #

 
24: Back in the Saddle


I first started watching 24, the show that features the wildly violent and incredibly entertaining escapades of Jack Bauer as he strives to thwart terrorists, three years ago at the start of Season Five (a.k.a. Day Five). I liked it immediately and posted my impressions at the start of that season, but never mentioned that I became steadily more hooked as it went along. By the end of the season I was madly in love with 24; it's the first time I ever watched an entire season of any show without missing an episode. A lot of that was due to the fantastic acting of the guest stars that season, including Sean Astin and Peter Weller, but most especially the duo of Jean Smart and Gregory Itzin, who played President and Mrs. Logan. In all honesty, I've never seen better acting on television. Smart and Itzin were both nominated for Emmys but, sadly, did not win (I maintain they were robbed).

Then came Day Six. It was awful, probably the biggest disappointment of any season of the show from what I've read on the TWOP boards. Nevertheless I kept watching, due to sheer determination I suppose - plus Keifer Sutherland does a consistently great job as Jack Bauer.

Day Seven was delayed for a year due to the writers' strike but has been worth waiting for. It isn't any more realistic than last season was - a major plot point involved a takeover of the White House by a dozen terrorist frogmen who swim from the Potomac and drill their way into the basement of the White House! But the characterization has been better all around, and the plot has been a lot tighter. The idea of getting rid of the CTU, Jack's former employer, and moving the action to the FBI actually worked, not least because it turned Jack and his former CTU compatriots into a plucky group of outsiders fighting pervasive corruption in the government. Also, the actress (Cherry Jones) playing the President this time is a heck of a lot better than whiny Wayne Palmer was last season. She was clearly pitched as a Hillary Clinton lookalike but has grown into the role really well. I always enjoy the scenes in which she faces down the (all-male) joint Chiefs of Staff. I was looking forward to watching Colm Feore as her husband, but sadly he wasn't given much to do as First Gentleman. Currently his character is recovering in the hospital after being kidnapped, tortured and shot. All sorts of lousy things happen to the characters on this show!

The writers wound up going back to the tried-and-true and recycling a lot of plot points from previous seasons, but I don't care. Even the creaky device of bringing a major character (Tony Almeida) back from the dead worked, once you get past the initial ridiculousness of it. This is due to the great chemistry between Sutherland and Carlos Bernard. What I can't wait for is the showdown between Jack and Tony, now that we've learned that Tony's a bad guy - as revealed at the end of the last episode when he murdered an FBI agent. Yes, Tony's not only Zombie Tony, he's Evil Zombie Tony! You can't beat that. And Glenn Morshower, as retired Secret Service Agent Aaron Pierce, was brought back and has made a solid contribution this season. Since all the other agents seem to be either incompetent or corrupt, I applauded the good sense of the President's daughter (she pulled him out of retirement to protect her). I'm hoping to see more of Aaron in the last several episodes.

I know this recap makes the show sound ridiculous, but you can't really criticize 24 for that. By which I mean not that it's above criticism, but that critiquing it is a pointless exercise. You're either caught up in the plot twists and wondering what's going to happen next, or it doesn't grip you at all.

Lastly, I'm including a hilarious video made by a fan who decided to see how 24 would work as a silent movie. The captions are great: take a look.

Labels: Pop Culture

posted by Dr. Alice at #

 
Conversations With My Father


I am sure I am not the only one faced with this situation, but my dad (though I dearly love him) is what you might call behind the times. I herewith submit a few examples of this fact.


Conversation One

Dad (apropos of nothing): I was listening to the radio driving home last night and this guy came on. And he talked, and he talked, and he talked. And then this band came on, and they played pretty good, but then the guy came back on and he just wouldn't stop talking!

Me (after I think for a minute): Was he talking about a place called Lake Wobegon?

Dad: Yeah, I think that was it.

Me: Dad, that was Garrison Keillor. People pay to hear him talk.

Dad: Well, I wanted to hear him shut up.


Conversation Two

This took place about ten years ago, back when Dad was still practicing medicine and when specialists could pay for fancy holiday parties.

Dad: Dr. X (a cardiologist) had this great party last weekend. He had a band that was like the Beatles, I guess. Your mother and I danced ourselves silly.

Me: Young Beatles or later Beatles?

Dad: Huh?

Me: Did they have short hair and wear suits?

Dad: Yep.

Me: Young Beatles.


Conversation Three

Dad (again apropos of nothing): What the hell is a blog?

Me: It stands for 'weblog.' It just means that people have, like, this journal or diary on the Internet. I have one.

Dad: You do??

Me: (sigh) Yes. Didn't Mom show you?

Labels: Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
Guys With Time on Their Hands

You're a bunch of guys in a rural area of the UK. Your resources: sheep, dogs and lots of Christmas lights. What do you do?

Would you believe Sheep Pong?



Great video. Hat tip to this fellow (who writes great stuff, BTW).

Labels: Pop Culture

posted by Dr. Alice at #

 
True Talent

If you have not yet seen Susan Boyle's performance on "Britain's Got Talent," go watch her here on YouTube. She won everyone over, including Simon Cowell, and for good reason. You don't often hear a voice like that, let alone from a totally unknown performer.

Labels: Pop Culture

posted by Dr. Alice at #

 
STD Screening



Via Yahoo!, I bring you a report on chlamydia screening which indicates that many women are still not getting tested for it. Would you like to hear a disturbing fact? Some insurance plans won't pay to test women for this disease. (I'm looking at YOU, Blue Cross PPO.) Unlike gonorrhea, which is not subtle, chlamydia is often clinically silent. It can scar up the fallopian tubes and induce infertility, and the infected person can transmit the disease to their partners without knowing that they are infected.

My advice: even if you have to pay for it, get tested. If you can't afford the test, find a free clinic and get it done there. And, of course, avoid infection by limiting your number of sexual partners and using condoms.

Labels: Medicine

posted by Dr. Alice at #

 
Tea and Taxes

Millions of Americans are paying their taxes today; in addition, thousands are participating in Tea Parties across the land to protest government spending and tax increases. Glenn Reynolds' essay today in the Wall Street Journal points out some interesting facts about the tax protests. This is a true groundswell movement which has just come into existence in the past few months. Without the Internet's ability to allow ordinary people to organize, a cross-country protest like this could never have happened. A few paranoiacs suggested the tea parties had been dreamed up and bankrolled by some large political group or other, but no one has enough money or organizational skills to mount something this big.

It will be interesting to see what happens next. As Reynolds points out, the movement could get bigger, give birth to a third political party - or flame out if everyone loses interest. I don't somehow think the last option is going to happen, at least not as long as the federal government keeps saying that spending mind-boggling amounts of money is the answer to all our problems.

Labels: Money, Politics

posted by Dr. Alice at #

 
"I Didn't Know it was Loaded!"

According to this report, it's becoming more common for patients to inject themselves accidentally with EpiPens. EpiPens are preloaded syringes of epinephrine which can be prescribed to patients who have severe allergies (i.e., bee stings or food allergies such as peanuts). The epinephrine is supposed to reverse the effects of anaphylaxis, ease breathing and give the patient time to get medical help. While undeniably useful, I have often wondered if these pens are over prescribed - I get a lot of requests for them. Surely not everyone is that allergic to bees? At any rate, the study reviewed 26 reports on accidental autoinjections, culled from medical journals over the past twenty years.

About 94 percent of these injections went into the thumb or finger instead of the thigh, where they are supposed to go. Fortunately not a lot of side effects were noted, "pins and needles" sensation being the most common. I was wondering if there had been any episodes of blood loss to the finger! I was always taught that using epinephrine to a "dead end" part of the body like the finger was a no-no as it could compromise the blood supply. No such complications were mentioned in the article, however.

If you are severely allergic to something, you probably need one of these pens. My preferred treatment, though, is liquid Benadryl (diphenhydramine). It's easy to swallow and gets into your system faster than the pills. I often recommend it as part of a travel medicine kit.

Labels: Medicine

posted by Dr. Alice at #

 
Answer of the Day

Patient presents with cough and chest cold symptoms for a month. I ask her what her phlegm looks like. Her answer: "Phlegm."

Labels: The Doctor's Life

posted by Dr. Alice at #

 
In Praise of Asparagus


'Tis the season for asparagus, falalalala, la la la la...

Forgive my transports. I love asparagus enough that I think carols should be written in its honor, and this is the high season for it. Bonus: it's on sale! Most supermarkets have asparagus at bargain prices this time of year.

Let's say you hit a sale or two and are stocked full of asparagus, and are looking to do something with it besides just boiling and eating it. (Though there is nothing wrong with that.) I would recommend the following recipe, which I got off the Simply Recipes website - an excellent reference site, BTW. If you are lucky and also manage to get ricotta on sale, you have an inexpensive dinner for four or five people. If you aren't feeding four or five, leftovers are good for lunch the next day.

1 1/4 lb thick asparagus, woody ends trimmed
1 lb penne pasta
1 clove garlic, peeled and mashed
15 oz ricotta cheese
2 T. olive oil
2/3 cup grated Parmesan cheese
salt, pepper
Nutmeg

Bring a 5-qt pot of water to the boil (you will use same water for cooking both the asparagus and the pasta). Add salt. Have an ice bath ready. Add the asparagus to the boiling water and cook about four minutes, till tender but firm. Remove asparagus and plunge into cold water to stop cooking. (I have a pot with a metal insert which makes this much easier: just pull out the metal insert and hold over the pot to drain. Tongs, however, are fine.) Drain the cooled asparagus and cut on the bias into 1/8 inch slices, leaving tips intact.

Bring the water in the pot back to a boil and throw in the pasta (you can use a little less than a pound, if you wish).

While pasta is cooking take the garlic and rub it all over the inside of your serving bowl; discard the garlic. Add the ricotta, olive oil and 1/4 cup of pasta cooking water to serving bowl and stir. Drain pasta when done (but reserve some extra cooking water). Add penne to the cheese mixture and fold in the asparagus and half of the Parmesan. Season with salt, pepper (white pepper is nice, if you have it) and several dashes of ground nutmeg. If too thick, add some of reserved pasta water.

Serve pasta with remaining Parmesan on side to sprinkle over. Serves 4 to 8, depending on whether it is a first course or the main course. You can add a little zested lemon peel if you'd like.

Labels: Ingestion

posted by Dr. Alice at #

 
Good Friday on Twitter

Trinity Wall Street is Twittering the Passion of Christ today (begins in about ten minutes). It sounds odd, but could be useful if you want to follow the story in real time.

I've become enamored of Twitter myself and unfortunately I've been posting a lot more there than here. It's less demanding, only 140 characters per entry are allowed.

UPDATE: Whoever handled the Twitter at Trinity apparently can't count, as they kept overrunning the 140 character limit. Overall: eh.

Labels: Episcopaliana

posted by Dr. Alice at #

 
Raymond Chandler



Died fifty years ago today. One of my favorite writers for many reasons, nicely encapsulated in this article. If you've never read him, do yourself a favor and go get some of his stuff.



(via L.A. Observed)

Labels: Los Angeles, Pop Culture

posted by Dr. Alice at #

 
"Snap" Isn't Good


OK. What shall we talk about today?

I know. Let's start with the telephone call I got yesterday from the ER. They were seeing a patient of mine, an elderly woman who's been bed bound for several years following a stroke. Yesterday while bathing her, the caregiver raised her (the patient's) arm so as to do a better job - and heard a loud SNAP.

That's how bad osteoporosis can get. You snap someone's humerus in two, just by raising their arm.

Granted, it usually isn't that bad. If you're immobile and non-weight bearing that really accelerates the process, and no, calcium supplement isn't going to be enough to fix that. Bone is like muscle in the sense of "Use it or lose it"; it reacts to being stressed by strengthening itself. Bones are active, not static; bone matrix is constantly being revised to respond to stress. This is why astronauts are at extra risk for osteoporosis. If you spend time in a zero gravity environment, bone strength decreases. Weight bearing exercise like walking, jogging, weights are all helpful in maintaining bone structure but swimming and stationary bicycling are not.

I spend a lot of time trying to convince patients to take medication for osteoporosis. Most patients, at least in my experience, think that calcium alone is enough. It's not, not if you are on that slippery slope of bone loss. But you should take calcium, and these days I recommend calcium citrate with vitamin D. Calcium citrate is more easily absorbed than calcium carbonate (the kind you get in antacids). Also, you need stomach acid to absorb calcium properly. There is evidence that long-term PPI or H2 blocker use (i.e., meds like ranitidine or omeprazole) can be a risk factor for osteoporosis because it means that you're absorbing less calcium.

We have lots of great new medications to treat bone loss now. Probably the most commonly used are the biphosphonates like alendronate and risedronate. (US brand names: Fosamax and Actonel.) These are the ones that can irritate the esophagus and have to be taken on an empty stomach, but they work the best. I also use raloxifene (Evista), mostly if someone can't tolerate a biphosphonate.

Why do we treat? It turns out that fractures are much more of a health risk than you'd think. Here's an article about mortality risk associated with hip fractures: in this study, a cohort of 120 elderly patients were followed after sustaining a fracture. Six months out, 18% had died and another 29% were institutionalized. That's 47 percent - nearly half - who never made it home.

Other risks for osteoporosis include being thin (hah), heavy caffeine intake, smoking and alcohol. Lifestyle does make a difference here, but the main risks are age and genetics. If osteoporosis runs in your family it means you have a higher risk of getting it.

My patient isn't a candidate for surgery. She's too frail and her bone quality is so bad the surgeon wouldn't be able to pin the bone. So she's in an immobilizer and she's lost the use of her good arm (the other one is the stroke-affected arm).

Take your calcium, exercise and cut back on the coffee.

Labels: Medicine

posted by Dr. Alice at #

 
May I See the Wine List?

V. just sent me a voicemail from one of the nursing homes where we often see patients. The charge nurse called to give V. a test result and then added: "The patient is requesting red wine with dinner. Please call us back."

Requesting wine with dinner, at a nursing home?

I voicemailed her back and suggested that the staff get some grape juice and pour rubbing alcohol in it - "He won't be able to tell the difference." Hmm. Chateau Geriatrique. Sounds catchy.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Float

As I watched the Oscars last night I thought back to a film I saw several months ago at an independent film festival. I meant to blog on it but somehow never got around to it. Independent films are a bit of a crapshoot; they can be either very good or very bad. You never quite know what you've let yourself in for, but I was eager to see this particular movie due to its star Gregory Itzin - you may know him better as President Logan from 24. The movie is called Float and is centered around the owner and employees of a Glendale ice cream parlor.

As it turned out, Float was a very pleasant surprise. I'm a sucker for anything with multiple plotlines, and this is an ensemble film where each of the actors gets their own story, so I sat back happily and watched. Two of the actors (not Itzin) co-wrote the script. One is Filipino, the other Armenian, and one of the pleasures of the film is the glimpse it gives the audience of the Armenian community in Glendale.

The plot is set in motion when Itzin's wife leaves him. He's playing Ray, a hardworking small business owner who clearly hasn't thought about anything but his job for years. When she leaves he's thrown for a loop and can't stand the thought of staying in his house alone. He camps out at the ice cream parlor but is discovered by his assistant manager, Gevorg. Gevorg is a fast-talking playboy type who's always running some sort of side business out of the ice cream parlor, but he's also kindhearted and takes Ray in to stay with him. Complicating matters is Ramon, a former employee who's been fired by Ray and is also staying with Gevorg.

Gevorg is somewhat estranged from his traditional Armenian family, particularly his father, who's running for city council. He meets and falls for Ray's daughter Emily, who works for an environmental organization and is somewhat estranged from her father as well. Meanwhile, Ramon has fallen for Gevorg's cousin, who wants to stay in the U.S. and is looking to marry an American citizen... you get the idea. Lots of stuff happens.

The film concludes with happy, or at least hopeful, endings all around. Greg Itzin does a very good job as Ray, the owner who rediscovers that there's more to life than work. He gets a tattoo, meets a nice woman and starts a new relationship.

Sadly, due to the competitive nature of independent films, it does not look as though Float is coming to a theater near you anytime soon. The last I checked the director was trying to get a deal for distribution of the film. Should that happen or if it makes its way onto DVD, I'd recommend it. The screenplay is witty, the acting is good and the relationships among the characters make for entertaining viewing.

Labels: Pop Culture

posted by Dr. Alice at #

 
Brief Early Oscar Review

I did not think I would be big into watching the Academy Awards this year, but here goes. Heath Ledger won the Supporting Actor award this year for playing the Joker... dull surprise. And I relieved my feelings at Bill Maher by flipping him the bird the entire time he was onscreen. (F*** you, Bill Maher. I hate you. No specific reason, I just hate you. No hard feelings, 'kay?) But he was not nominated, which made me feel better.

Updates as they happen.

UPDATE: YES!! The sound team for "Slumdog Millionaire" won. They look so excited. I really think this movie is the underdog film that everyone is rooting for.

...and SM just won for film editing. Go, go, go, guys.

AND AGAIN: Ah, gee whiz. So nice that Eddie Murphy is giving Jerry Lewis his props. The man has raised untold amounts of money for muscular dystrophy.

ONE MORE: Best Original Song: After watching the talented cast of SM dance and dart across the stage, who could doubt that they would win? And they did not fail... SM did win.

AGAIN: The Obligatory Salute to Those Who Have Gone Before Us is moving, due to the inclusion of Charlton Heston, Cyd Charisse and Paul Newman.

AND ANOTHER: Wow, Danny Boyle as Best Director for SM. I think I spot a trend.

HEY: Kate Winslet cops the little gold statue! Good for her!

UPDATE: Dang, Anthony Hopkins is near 'bout as bald as Ben Kingsley. And we have the obligatory quip about Sean Penn and the paparazzi.

... and of the Brat Pack nominees, Sean Penn cops it. (Why was Mickey Rourke wearing sunglasses indoors at night??) Gee, thanks for the preachy acceptance speech, Sean.

UPDATE: Best Picture montage was v.v.g.

UPDATE: Slumdog Millionaire gets it!! Well done!

FINAL UPDATE: Wait, wait. Where was my federally mandated George Clooney sighting in all of this? Did I miss him? Either I did or I was robbed. Robbed, I tell you!

Labels: Pop Culture

posted by Dr. Alice at #

 
Parenthood: The Real Story

Sometimes, The Onion just tells it like it is. I thought this was hilarious. But then again, I don't have kids.

Labels: Pop Culture

posted by Dr. Alice at #

 
Using Up Leftovers


Sometimes I open the fridge and find myself confronted by something I bought that I need to use up. This time it was ricotta cheese. I had bought it on sale and made lasagna with some of it, but there was still a fair amount left. What to do with it?

I thought of manicotti, but I had had my fill of Italian food for the moment just finishing the lasagna before it went bad. So I got on the Internet and started searching. (Some view the Internet as a bottomless well of news and politics; some see it as a warehouse for dirty pictures. For me it's the world's biggest cookbook.) Most of the recipes I found were for muffins. I picked the simplest recipe I could find, one that would not involve me having to purchase more ingredients just to use up the ricotta. It turned out to be Lemon Ricotta Muffins, and I liked them so much that I made them a second time and decided to post the recipe (with a minor alteration).

The single most important thing about baking with ricotta, I have found, is to make sure your baking powder is fresh. The first time I made these they came out a little... dense. Actually they were plutonium-level dense, but they still tasted good. I knew I had had my baking powder for a while, so I checked the can and found that the expiration date on it was 1997. I now have a nice new can of baking powder, and the second batch of muffins came out as advertised. I also added a tablespoon of lemon juice to the batter, which was not in the original recipe. This both boosts the lemon flavor and adds some oomph to the leavening.

So here is the recipe as I make it. Yields one dozen muffins.

2 cups flour, sifted
1/2 cup + 2 T. sugar
2 1/2 t. baking powder (FRESH!)
1/2 t. salt
1 cup ricotta cheese (You can use skim or whole-fat ricotta here, it doesn't matter)
1/3 cup milk
6 T. melted and cooled butter
2 eggs
3 t. lemon peel, zested
1 T. lemon juice

Preheat the oven to 400 degrees and grease a muffin pan (or use liners).

In a large bowl stir together the flour, 1/2 cup sugar, baking powder and salt. You are going to mix the batter in here, so make sure it is a large bowl. In a smaller bowl stir together the ricotta, milk, butter, eggs, lemon peel and lemon juice; when well combined pour this into the flour mixture and beat only until just combined. Do not overbeat; batter should be a little lumpy. Spoon into the prepared pan and sprinkle each muffin with 1/2 teaspoon of sugar (that's the additional two tablespoons mentioned above). Bake 20 to 22 minutes.

These are really good and don't take that long to make. You can save time by mixing the dry ingredients together the night before. Zesting the lemon peel is made much faster if you have a Microplane grater; if you don't have one, get one. It is a marvelous invention.

Labels: Ingestion

posted by Dr. Alice at #

 
It's Been That Kind of Week

Labels: The Doctor's Life

posted by Dr. Alice at #

 
It Has Come To This

So there's this drug called Amitiza, used to treat severe chronic constipation. Most people don't need it; you put them on prunes or spinach and explain to them that they are supposed to eat five to seven fruits/vegetables per day and not per week, and they do fine.

But some people do need it. I have one patient who does. Today I had to call his insurance company to get the drug re-authorized, and this is what ensued:



Pharmacy Benefit Rep: "What is the frequency of the patient's bowel movements on the medication?"



Me: "Whaa?"



PBR: "How often is he having bowel movements?"



Me: "He has not shared that information with me."



PBR: "We need to know that before I can authorize the Amitiza."



So now I have to call up my patient and ask him how frequently he, uh, goes. What a surreal conversation that's going to be.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
On Call: Rules of the Game


As I sit at my desk facing another night on call, I thought perhaps I might do my good deed for the day by posting a few etiquette suggestions.

• To the anxious relative calling from three thousand miles away: You are running up your phone bill for nothing. If you want to get your money's worth you should probably call during office hours so that you can talk to your parent's ACTUAL DOCTOR. I can guarantee you that if you talk to me we will both wind up frustrated. I can't read my partners' minds, and I can't tell you what Dr. X was thinking when he ordered Drug A instead of Drug B or why he sent your parent to Nursing Home Alpha Beta Gamma instead of Whiskey Tango Foxtrot.



• Also, if you are a grumpy patient looking for ammunition to bolster your claim that Dr. X makes terrible clinical decisions you won't get it from me. Even if that is the case (which I am happy to say is highly unlikely, at least in my group) there's no way in hell I'd tell you that over the phone. That way lies madness, not to mention malpractice suits. If I have a real question about care I will raise it directly with the doctor himself/herself, and I will assure you of my intention to pursue it and then get back to you. Rarely do I need to do this, but it happens once or twice a year.



• If you are sitting in the ER waiting to be seen, you have my sincere sympathy, but I do not run the triage department and I cannot get you seen any faster. Please do not call me.



• If you are an elderly neurotic with a grudge against your family because they dared (how dare they!) to go away for the holidays without you, even though they made arrangements for you to get regular home care while they were gone, and you call me to ask if you should file a complaint with Adult Protective Services, I will make you sorry that you were ever born. I am not making this up - I actually got this call.



• If it's likely that you will need a prescription, please have a pharmacy number in mind before you call me. If it's the middle of the night or a holiday, please make sure it is a 24-hour pharmacy. Do you want the prescription or not?

Thank you.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
Too Funny



Hat tip to Treacher for his link to this website. You can Obama-fy any picture you'd like. As follows:



Or this one:



Or this one!

Labels: Pop Culture

posted by Dr. Alice at #

 
I'm Home


Q: How do you know when you're back in L.A.?

A: You wake to the drone of a helicopter hovering in your neighborhood.

Finally, I'm back. This is the longest vacation I've taken in quite some time (I got back to the US yesterday and don't go back to work till Friday). The 10 freeway is down due to fatal accident - apparently some dude driving the wrong way. It happened in my neck of the woods, so I assume traffic on city streets is going to be really bad; have not left the house yet to test this theory.


It was one of those "herd 'em on the bus and go out to see the sights" kind of vacations, but considering we were in the Middle East this was by far the best option to choose. Specifically, my parents, my aunt and I toured Egypt and Jordan. I'm really glad we went and I would recommend both of these countries as destinations, should you be wondering whether to go. We saw Roman ruins, monasteries, mosques, Biblical sites and (of course) the Pyramids. Flat Stanley played a large part in our tour as well and I'm glad he did, as it forced me to do some actual research and learn something about the area we were touring. We will hear from Flat Stanley in a later post.

Our Egyptian tour guide was a sharp, amusing and tall fellow by the name of Achmed, very fluent in English. He gave us tons of information about Egyptian society, politics and history. His catchphrase was "Everything started in Egypt," and by the time he got through with us this didn't seem like much of an exaggeration. He's a self-described agnostic and was quite insistent that we not cover our heads at any of the mosques we toured - this stance actually got us evicted from one site. No one was wearing low-cut shirts or anything the least bit provocative, but the moment we entered the Al Azhar Mosque in Cairo we were surrounded by a group of locals (no imams or anyone with authority, just kibitzers) and after five minutes of heated argument from Achmed, we left. Interestingly, when we toured a mosque in Jordan - supposedly a more developed/Westernized country - all the women in our party had to put on hooded robes that covered everything, including our heads. We did as we were told but were not particularly happy about it.

Achmed also had some interesting analysis for us about how Egypt views the US, particularly its presidents. They loved JFK (predictably), but interestingly Nixon is respected there as well. This is partly because of his progressive stance on foreign policy and partly because, in the Middle East, Watergate is viewed pretty much as business as usual (Achmed quote: "What's the big deal?"). Per Achmed, the Egyptians really liked Clinton and hated GWB. When asked to comment further, he explained: "Bush should never have used the word 'crusade' after 9/11. The Crusades are a very bad memory in this part of the world. Then, when he said 'You are either with us or against us', this sounds like bin Laden. The people here, they don't like bin Laden either, but a bin Laden in a cave is no problem. He can't hurt anybody. A bin Laden in the White House, this is a big problem."

Achmed also had some cogent comments the day of Obama's inauguration. "Nothing's going to change," he said, shaking his head. "Everybody here is so happy because they think Obama is going to change everything. But that is not the way your government is set up. It's not like here, where the head of state can do anything he wants. Nothing is going to change." Give that man a cigar, I thought. He's got American politics figured out better than most Americans.

We did all watch the inauguration at our hotel in Luxor (it was 7 pm local time). The hotel had set up chairs for us in the lounge area. I hadn't felt strongly one way or the other about watching, but decided to join the group. It isn't partisan, but I just don't have much attention span for this sort of thing. Perhaps it's a character flaw, but Big Moments generally leave me uninterested, particularly if they involve speeches. I did feel sorry for the Obama kids, though, having to sit out of doors in the freezing cold. Their noses were clearly running.

A side comment re: the inauguration. I spent a lot of time catching up on blogs today, and if I see one more comment along the lines of "I was so happy I've been in tears all day" I'm going to hurl. Seriously, people, get a life. My thoughts were more along the lines of Went well, nice speech, let's get on with it.

And now I've got to get on with it and go run some errands. More later.

Labels: Travel

posted by Dr. Alice at #

 
Off Track

I'm going to be off the map for a bit; back at end of January. I'm traveling with my parents. Will let you know about it upon my return.

Labels: Travel

posted by Dr. Alice at #

 
The Doctors' Lounge



As the kid of an MD I spent quite a lot of time - on Sundays, mostly - hanging out in hospitals. I used to sit and draw at the nurses' station as Dad rounded on patients. I recall meeting a pathologist who showed me some sort of chemical trick invoving phenolphthalein, which turned a colorless solution bright pink [or perhaps vice versa] - and then, for a finale, he drank it. (I am not making this up, I swear, and I know it involved phenolphthalein, but I don't recall the exact details. Any chemists out there want to help me out?) And I ate more Sunday dinners than I care to contemplate at the hospital cafeteria. This may be the source of my affection for greasy-spoon food: Anything is a step up after that.

But the Doctors' Lounge was Terra Incognita. We only went there with Dad. He had to be there to give us the entree. Never mind that on Sunday afternoons there was usually only a solitary surgeon or anesthesiologist there watching sports on TV: to get in we had to be with Dad. It was a manly sort of place (this was the mid-1970's we're talking about) and only Real Doctors hung out there.

I can still see the Lounge with its walnut paneled television in the corner, harvest gold upholstered couches and relentlessly bright, upbeat recessed ceiling lighting as though it were yesterday. That Lounge and the hospital that contained it no longer exists; it was torn down years ago (they built Assisted Living housing for seniors there in its place), but no matter. Every Doctors' Lounge I have ever been in was spiritually, if not physically, the same.

Recently I've been thinking a lot about Doctors' Lounges because I've been spending a lot of time in them - specifically in the Lounge of Tertiary Medical Care Center. This is because I spend many Thursday mornings there for meetings. (If you are on staff at a hospital you immediately get hit up to serve on one or more committees. This is not absolutely mandatory, but only in the technical sense, so you might as well say yes. Being efficient, I chose only committees that meet on Thursdays - my day out of the office.)

At any rate, Tertiary MCC has a pretty good Doctors' Lounge as these things go. It has windows, it has two televisions (and two computers), it has its own bathrooms, and it has free bagels and coffee (and bagel schmears) on weekday mornings. These may sound like minor details but trust me, they are not. If you have to drag yourself to the hospital at crack of dawn it will mean a lot to you to have coffee and something to eat when you get there. Likewise, if you have to spend weekends/holidays/Super Bowls at your workplace you will thank God to have a clean, well-lighted place for television there.

I don't have air conditioning in my house, but TMCC does. In the summers that's important too. Therefore I have developed the habit of going to where I know I can get a decent bagel and cup of coffee, hang out, read the paper, schmooze and get work done - in short, the DL. The TMCC's computer system links to the Firm's electronic medical record system, so I can check labs and make phone calls while I'm waiting for my meetings to start. My efficiency increases exponentially while I'm there since you can't blog or surf the Net with some rabid intern breathing down your neck waiting to use the computer.

In the Doctors' Lounge the television is always on and is always showing either news or sports. Female MDs are welcome, but you don't seem to see that many of them (except for the house staff) - decades after my initial exposure to it the DL is still mostly a manly place... perhaps the women have better things to do? There's always at least one retired MD reading the paper, arguing politics with somebody or watching TV. In our lounge there is one extremely elderly fellow who always seems to be there, and he gets there early: I arrived just before seven a.m. today and he showed up about fifteen minutes later. Interestingly, he seems to have no sense of time as he spent the 45 minutes or so before my meeting making social calls on the phone. (I heard "Oh, did I wake you up?" twice as I was checking labs and eating my bagel.)

He is also hard of hearing. A friend of his came over and initiated the following conversation:

"Did you get your juice today?" (repeated three times)

My elderly friend finally registered the inquiry, blinked and answered: "You'll have to come over here. I can't hear you."

Question repeated, he answered triumphantly: "Yes! I got my juice already!"

Such is life in the Doctors' Lounge.

Oops, he just wandered back in - gotta go before he reads this!

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #